2000 TRAI{SACTIOI\}5 AMERICAl\ OTOLOGICAL SOCIETY, II{C. 2000
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VOLUMT 88 ONE HUNDRED THIRTY-THIRD AN}JUAL MEETiT{C Onlalro Wonln CtrurtR Manirro:r ORr-,rNno, FloRrna Mev 13*14,2000
-db,.Y LrprrNcorr WTLLTAMS fc Wu ANNUAL PHOTOCRAPH vtl 2OOO OFFICFITS vill 2001 0rncERS v[t INTRODUCTI0N or AW,{RD or MlRtr wtF.lNER: RoBTRT H. JAHRSD0ERTIR, M.]. IX Charles Luetie, M.D. AWARD OF MERIT RECIPIE\]TS 1949*2OOO cuESTS OF HOt{OR .1 949*2000 SCITNTITIC STSSIONS 2OOO PRTSIDENTIAL ADDRESS . C. Cary jackson, M"D. INTqODUCTION OT CUIST OF HOI'JOR: DTRALD f. SRACKMANN. M.D. C. Cary lackson, M.D. RI:MARKS Or CUEST 0r H0NOR Deralcl E. Brackmann, M.D. PRTSENTATION OF PRESTD[N1TIAL CITATION: WltLlAM B. WILLIAMS, ESQ. C. Cary Jacksr:n, M"D. R[SPOT{ST OT PRT$iDENTIAL CITATION RTCIPILNT \Alillianr B. Williams, Esq. MIDDLT ffiRIMASTOID -I. FTLINE IMMUNOD[':ICIENCY VIRUS*MIDIATTD CTNI TI'1IRAPY OF MID}LE TAR MUCOSA L,LLLJ.rTI I C Hamid R. Djalilian, M.D., Yasuhiro Tsu[:roi, M.D., wesley obritsch, antj Jizhen Lin, M D, :. ANALYSIS OF THI DYSFUNCTIONAL EUSTACHIAN TUB[ BY VI}EO II"{DOSCOPY" Dennis s. Poe, M.D., Ashraf A. Halawa, M.B.B.ch., M.s., and osama A. Razek, M.B"B.ch., M.s. 3. I.,{S[R STAPEDOTOMY WITH CONSTRVATION OF THE STArr}IAL TTNDON. Rodney C. Perkins, M.D. 4. CURREI\IT USE OT IMPLANTS MIDDLL EAR SURCERY Robrrt A" Coldenberg, M.L)", and'N John R. In'rmett, M.D., t A"C"S. DISCUSSION PERIOD l: MIDDLI IARIMASTOID TO 5. ViBRATORY SAMPLI MACNETOMtrTRY OT ST,APTS PROSTHESFS TO ASSESS MR SATEIY ANil COMPATIBIIITY 12 Mark J. Syms, M.D., and Derrick W. Peterman, Ph.D. MID}L[ EAR PROSTI'1ISIS DISPLACIMENT I1\ HICH STRENCTH MACNTTIC TITL}S '13 Michells D. will!ams, M.s.4, Patrick J. Antonelli, M.D., F",{.c.s., and Lorna williams, M.D, PROCNOSTIC fACTORS ll'l OSSICULOPLASTY: A STATISTICAL STACII"iC SYSTEM . 1r4 John L. Dornhofier, M.ll., and Edward K. Cardner, M.D" lI1 DISCUSSION PIRIOD ll: tullDDLE EARIMASTOID 15 PANEL DISCUSSION: CHOLESTTATOMA 16 S. ANTTRiOR SUBANN]ULAR T-TU1]T FOR PR.OLONCTD MIDDLE TAR VINTILATION DURINC TYMPANOPLASTY: LONC-TIRMFOLLOW-UP...... "..." 22 Ravincjhra C. Illuru, M.D., Ph.D., Reena Dlranda, M.D", Joel A. Coebel, M.D., F.A.C.S., and I. Cail Neely, M.D., f.A.C.5. 9" DELAYID FACIAL PALSY ATTIR STAPEDECTOMY Z4 Xianxi Ce, M.D.. and ]ohn l. Slrea, Jr., M.D" 10. INCIDINCI OT FACIAL NERVE DIHISCENC,E AT SURCIRY TOR CHOLESTIATOMA 25 Samuel H. Selesnick, M.D., F.A.C.S., and Aiaslair C. Lynn-Macrae, M.S. DrSCUSSION ptRl0D lll 26 n4i^vrtnrs DrsrAsr "11. A COMPARISON OT HIARINC RTSULTS IN INI RATYMPANIC IINTAMICIN THTRAPY 27 Michelie L. Facer, D.(J., Ci;lin L. W. Drisr:o:1, M.D., Stephen C. Harner, M.D., Ceorge W. Iacer, M.D", Charles W. Beatty, M.D., and Thonras J' McDonalcj, M"D. 12. tMPACT Or Mf NTERTS DlSl-A5E ON QUALITY OF l-lFE 28 .lolrn P. Anderson, Ph.D., arrd jeffrey P. l-{arris, M.D., Ph.D. ] 3. THT WANINC ITOLE OF \IFSTIBULAR NERVE STCTION AND LAI3YRINTI-{HCTOMY TOR INTRACTABLE MENIER['S DISIASE 2q Anis A. Ahmadi, 8"5", Patrick J. Antonelli, M.D., and Ceorge T. Singleton, M.D. DtscusstoN PERIOD lv: mrxllnrs DlstASr 30 IMPLANTABLE DEVICTS "I4. IMPTANTATION OT THE SEVTI?TLY MALFORMED COCHLTA 32 Andrew J. Fishman, M.tf ., J. Thomas RolantJ, M.D., Ceorge Alexiades, M.D., and Notll L. Cohen, M"D. i5- THE MAI\ACTMI-I\I OF FAIi.NDVANCTD OTOSCLEROSIS IN IHE ERA OT COCHLEAR IMPIANTATION )1 Michael ]. Rucker"rstein, M"D., M.S.. F.A.C.S., i(ristine O. Rafter, M.A., and Douglas C" Bigelow, M.D. 16" IS COCHLEAR IMPLANIATION POSSIBLE AITER ACOUSTIC TUMOR RTMOVALI 34 Aziz Belal, M"D. 17. ADULT COCHLTAR IMPLANT PATIINT PTRTORMANCE WITH NEW ILECTRODT 35 IECHNOLOCY " . Terry Zwr:lan, Ph.D., Paul R. Kileny, Ph.D., Sharon Smith, M.S., Dawna Mills, M.S., and Mary loe Ogberger, Ph.D. DISCUSSION r[RIOD V: IMPLANTABLE DEVICIS 36 .I8. HLARINC R[}-JABILITATION US INC THI BAHA BONE.ANCHORED HEARINC AID: RESULTS IN 40PATIENTS..". 3B Lawrence R. Lustig, M.D, H Alexander Arts, M.D., Derald [. Bracknrann, M'D., Howard F Francis, M.D., Tim N4olony, M.D., Cliff A. Megerian, M.D., Cary F^ Moore, M.D. F.A.C.S., Karen M Moore, M.A., Trislr Morlovt,, M.A., Williarrr Potsic, M.D., Jay-f. Rubenstein, M.l)., Sharmilla Srireddy, M.S., Charles A. Synrs llt, M.D., F.A.C.S., Cail lakahashi, David Vernick, M"D., Plrillip A. Wackym, M.D., F.A.C.S., John K. Niparko, M.D. '19 EDITOR'S NOIf; Abstract was nol presentecl at the meeting. 20. UPDATE ON CONSTRVATIVI MANACEMENT OT PATIENTS WITH ACOUSTIC NEUR()MAS . . , . 40 Dick l. lloistad, M.D., ceorge A. Melrrik,,\4.D., Bulent MamikoglL.r, M.D., cathleen A. O'Connor, M.5^, and Richard J. Wiet, M.D., F.A.C.S. 21. COMPARISON OF THE I(I_67 AND C-TOs STAININC PATTTRN IN CLOMUS IUCULARE AND C LOMUS TYMPANICUM TUMORS 41 Mohammed Mujtaba, M.D., l. Thomas Roland, M.D., Dennis C" Pappas, M.D., ancJ Dearr I Hilman, Ph.D" DISCUSSION PERIOD Vl: HEARINC LOSS/|NNER IAR *2 HfAtrrNG rOSSy'rNNrr rAn 22. ETANIRCEPT TI--IIRAPY FOR IMMUNT-MEDIATID COCHLIOVESTIBULAR DISORDERS: PREI-IMINARY RESULTS IN A PILOT STUDY 44 l{yon K. choi, M.D., M.P.H., Dennis 5" Poe, M.D., and Mahboob LJ. Rahman, M.D., ph"D. 23. RISK TACTORS TOR HEARINC LOSS II*,] NTONATES 45 Stilianos E. Kountal 24. LI)OCAINE PTRFUSION OF THE iNNER TAR PLUS IV LIDOCAINI FOR TINNITUS 46 john J. Shea, |r., M.D., and Xianxi Ce, M"D. ROLT 25. OF IMAfiINC IN THI CLINICAL DIACNOSIS OF INNIR EAR DISORDtRS 47 Arvind l(umar, M.D., Mahmood Mahfee, M.D., Scott W" DiVenere, M.D., and Han Soo Bae, B"S" DISCUSSION PERIOD Vll: HIAR|NC tOSS/tNNIR EAR !t8 PANET DISCUSS:ON: ACOUSTTC NfUROMA 50 H t sTo?AT H OLOAy/VrSn B U LAR D I SORD qRS/AN ATOMY 26. AN INIERACTIVE THRIE-DIMINSIONAL COMPUTTR MODTL OF THT TEMPORAT BONE . . " 5{1 Masayuki lnouye, M.D", Joseph Roherson, M.D., Kevin Montgomery, ph.D., ancJ Michael Stephanides, M.D. 27. HISTOPATHO1OCY OT RESIDUAL AND RECURRINT CONDUCTIVT HEARINC LOSS FOLLOWI NC STAPE DECTOMY 59 Joseph B. Nadol, Jr., M.D. 28. I-'IISTOLOCIC STUDI[S OF THE POSTTRIOR STAPEDIOVESTIBULAR JOINT IN OTOSCLEROSIS llt saumil N. Merchant, M.D., Armagan rncesulu, M.D., Robert J. clynn, sc.D., and Joseph B. Nadol, Jr., M.D. :9. A COMPARISON OF ENC RESUTTS WITH POSTUROCRAPHY FINDINCS FROM THE BALANCETRAK 5OO 62 Manali Amin, M.lf., Marian Cirardi, M.A., Horst R. Konrad, M.D., and Larry F. Hughes, ph"D. 3I}. A VESI"IBULAR PHENOTYPE rOR WAARDTNBURC'S SYNDROMT? 53 t-. o. Bl,rck M.D.. I .A.C.S., 5. C. Pesznecker, R.N., K. Allen, M.S., and Claire Cianna, ph.D" D: scussloN P:RloD vl I I : H I SToPATHoLocy/vrsI s u tAR DrsoRDlRSlANAToMy INTRODUCTION OF NEW PRISIDENT: A. ,ULIANA CULYA, M.D 65 C. Cary Jacl REMARKS OF NTW PRESIDENT 65 A. Juliana Culya, M.D. EXTCUTIVE SESSIONS 66 Business Meeting Repttrts Secretaqz-Trsasu rer 6b b7 Ed itor-l-rhrariarr t)7 Board o{ Trustees of A(JS Rtse;rch }'urd . Americarr Board of Otolaryngology . . 67 Anrerica r.l Academy of ()ttllaryrrgology 67 American College o{ SLirg,r:ons 68 Ar,vard of Meril C*mnittee t)o Audit Comnritiee 6B |l.) Nominating Comtliueo . ln Memorianr Cesar Fernanciez, M.D" 7A W. Hugh Powers, M"D. 72 Menrbers l\clr Mt'n rbr'rs 73 Artrvc 75 77 Senior . . ?o Imerilus 78 ,Associate 79 Correspondirll . " . Hr;norarv 79 Deceased t}0 Index Subject u.l Author {}2 \r1 ro ,/' _U ^4,:,i c .,,Y, .iU 't *>--Ct.Y-W:+tdV - - 1 .. ^ I Yr -^-'_: da\ > -'_lxa_- '- v) tJ L.-+^/- - 6lm rJ-. .u-l\t c-L --<' -< i rt-E - iixLnia,0:- t{Y!ra) u Cl "- (, J U ..at^r,x -i* .,)?^;.^9: :.v9>E : 9 -- o< *- H c; ^;--2-.n ..--'^!-i-r-: !-^ vLq"Y- :l O - :!^!: M a __ >& .\ = -....qVr!'\rn Ld_' z{z'! - . 1> L 3 j ,:c,'Lr,itr :v!!L=4^a: I M L - ^^.- L . . >- L - V ? l, ! iJ ; - C *-h;'d't:'-- ; " -! ri Y :r { co o- u:;- -- t)LU._tt-:-, ,m,,vul .aF ^ -;>**t-l i:&; > bou^; vc4---g:^o 6=-r o o<;' u-::l' -C:,ro\-:!;- i;p-,Egr. j> u-7, -: r r'-v I^ -:r,L!m^ *^-4-- -.n.Y >= .9Y>A=>* .-Y |- r, L- *o\z/ > ';tO-(r).J-3*q.;> J(l^40-v v: - .r >; N o,4x i: -* p iz 9 a .{ ': (-) -: --: l-".1 2 AMERICA\I OTOLOC]CAL SOCIETY 2OOO OFFICERS ?OO1 OFFICERS PIIIJSlDENT iIRES}DHNT c. GARY ]ACKSON, M.D. A" JUL:ANNA GULYA, M.D" ]]}TESIDENIT-ELECT / IDlTOR.LlTITARI A}'J PRLiS]DENT-lILIC i' A. JULIANNA CULYA, M.D RICHARD A CHOLT, M.D., Ph.D. SECRIiTARY'TREASIJRLlt SHCRTTARY.TRIASURER HORST R. KONRAD, M"D. HORST R. KONRAD, M,}. F,Df IOR-LIBRA RlAN -ELECT EDITOR-LIBl1ARI.AN SAM E. KIN}JEY, M"D. SAM E. KINNEY, M.D. COLINC1L COUNCII-, The abave of{icers and The above nffieers and CHARLES 1\,1. LUETiE, M.D. GRECORY J' MATZ, M'D. CREGORY I" MATZ, M.D. c. GARY IACKSOI{, M.D. RICHARD A. CHOLE, M.D., ph"D" JEFFREY P. HARRIS, M.D., Ph.D. JEFpI€Y P. HARRIS, N,{.D., Ph.D. }OHN K. NITARKO, M.D. \rtIl INTRONUCTION OT AWAR) OT MIRIT WINNTR Chtrrlcs Lrttt je, M.l). lt is ;r great pleasure as past President of the American Otolcgicai Society to presert to you our Award of Merit winner. Our first slide shoro,,s our Award of Merit winner w'ith all ser.,en brothers and sistcrs. The aw'ardee was bom in New York and lrald four brothers and tr,r,'o sister:s. He developed a flare for: fasl cnrs at an early age, alrtl also learned to enjoy water sports. His fath*r felt it was irnportant to keep the family together, and every *ther SLrnclay he wor.rld drive the "1932 Buick {ronr Glendale, Queens, Nlew York, to Lake Rori Kon l(ama" Llur Award of Merrit winncr 1or.ed all kinds nf sports, particularly football. lle was a champion on his baskeiball team. To rlarn money during the early days, our awar- dee collected live Jnpanese beetles and sold them for firre cents a pound, and fetched golf bal1s. He also worked at an ice cream parlor. l:Ie always seemecl to work late or com* homtl laie. The real r:eason rtras that he arrd his bnrther shared a room. Each lrad a window. l-{c r,r,antr:d it w'arm, window ciosed, and his brolher wanted it cold, window open. Tl'ris didl't work, and it was agr"eed that the Rohert H. h,1.1). last one in would control the window. Jahrsdo*rier. Ou:: Award of Merit r,rrinner has alwirvs been irr- lerested in being physically fit. l-{e had other hob- versity of Virginia School of Medicine in 1961. After bics. A direct quote fron"r his Lrrotl'rer is, "He wa$ cornple ling his residenc)r at Yale*Neur Haven Hos- known;rs a ladies' mar1." ln higlr school he was sil pital in 1965, he joined the faculty at the lJniversitv struck by tlre apprarance of the briauty qreen, Ms. of Virgirria. In 1982 he moved to Houstan to aceept Stt:el Fier, across the rirrer in lr.ler,r, Jersey, he was thc chairmanship of the L)iolaryngology Department able to ge I a date with her. This fame continued intir the of Texas; ire to "rt Univr:rsity returncd the Univer- his fir:st year at collcge. }lc r,vas the first to go tc) sity of Virginia in 1995. As can be sren, or-rr Aw'ard of college-in Rochester, Ner,r, York. Hc was selected Merit honoree is Rnhert H. Jahrsdrer{er, N{.D. by Kodak to appear for a poster that hr"rng in Crand Our Anrard of Merit winner's maay accomplish- Central Station. Ah, yes, college lifc was good. menls include recciving thc 1978 Triological Soc! College life was expensive. It r,rras rrol exacily pro- ety's Mosher Awarrl for work nn colrgenilal atresia. ceeding the wav his iathel lracl in nrind. The fund- He is ;rlso past vicc president of the Triological So- ing was cut off, and our Ar,r,;rrd ol l\4erit u'inner' ciety-Soutlrern Section, past president of the joined the Navy ior tlrree yetrrs. American ]).frulotology Socicty, and past president BasketLrall continued, in addition to his duties, nf our own Otcilogical Society" His own personal and aerial photograph)r" He is seen in this picture experience in sr:rgery fnr congenital aural .rtresia home *n leave in 1957. After tlre Navy he enrolled exceeds 1,200 cases, and his expertise is known the in Geolge Waslrirrgton Urriversity, and so di<1 90"1, lr'rorkl orrer. lt is a pleasure tri introclucn to the mellr- of his brotirers' clothes, 1 was told" He receirred l"ris bers of tlre American Otological Society l)r. Robert H. undergraduate degree irorn Ceorge Washington. Jahrsdoerfer as our Award of Merit winner on tire He then r"eceived his medical dcgree fronr the Uni- occasioll uf the 133rd .Annual M**ting of ihe Society. 'tx AWARN OF MERIT RICIPIINTS 1949*2OOO 1949 Cer:rgc M. Coatcs, M.Il). 1978 ir:er5;en Tomrdr:rf, M.l)" 1951 Barry J. Anso:r, ?h.l)., and 1979 ]ohn E" *ordley, M.D. Theodore H" Bast, Ph.D. 1980 Ben H. Senturia, M.D. 1952 Edmund I)" Fnwler. M.D. 1981 J. Brown Farrior, M.l). 1953 Julius l".r:rnper:i, M.D" 1982 William F" House, M.D. 1954 Stacy R. Cuild, M.D. 1Q83 Victor Coodhitl, M.D. 1957 Ceorg r.on B6sk5sy, Ph.l). 1984 Harold F. SchLrknecht, M.D. 195S Ir. Cien Wever, Itrh"D. 1985 Wcsk:y H. Br:adley, M"D. 1960 Hallowell Davis, M.D. 1986 lohn I" Shea Jr", M"]1. 1A61John R. Lindsay, M.D. 1987]ack V. Hough, M.D. .1962 William ]. Mci{ally, M"D. 198E Ceorge T. l'Jager, N,l.D. 1965 Anderson C. l{ilding, M.Il. 1989 Brian F. McCabe, M.D. 1966 Gorelon D. Hoople, M"D. 1990 Eugene L. llerlacki, M.D" 19tr7 Merle Lawrence, ?h.lJ. 1991 Richard R. Cacek, M.D. 1968 Lawrence R" Boies, M"D. 1992 James L. $heehy, M.D. 1a69 Sir Tereace Cawthorne 1993 Janres A" Donaldson, M.I). 1970 Senalar Jcseph Sullivan, M.B. 1994 Fr:ed H" Linthicum, lr., M.IJ. 1971 Samuel Rcrsen, M.D. :995 D. Thane 11" Cr:dy, M.D", Ph.D. 1972 Howard P. House, M.D. 1995 F. Blair Simmorrs, M"D. 1973 Mr:ses H" l-urie, M.D. 1997 Michael E. Classcock lll, l\4.D. 1974 Ceorge E. Shambaugh, Jr", M.D 1998 Michael M. Paparella, M.I)" 1975 Catherinc A. Smith, Ph.D. 1999 Mansfield F. W" Smith, M.D., h,{.S. 197fi Harry Rosenwasser, M"l). 2000 Rabert A. ]ahrscioerfer, M.D" 1977 Frank }). Lalhrop, M.D. cu:5T5 ()r HoNoR 1949*2000 1949 Han"is P. Moshrr, M.D. l9TSHorvard P. House, M.O. 1950 D. Harold Walker, h{"D" 1.]79 Hallowell Davis, M.D. 1951 |ohn Mackeirzie Brown, M"I) lQ80 Victor Coodhill, M.D" 1952 Idn:rrrnd P. Fr:wler, M.D. l98l Harolcl F. Sclruknecht, M.D. 1q53 H. I. Lillie, M.D. 1982 Ceorge E. Shamlraugh, jr., M.D. 1956 Stacy R. Cuild, Ph.D. ltl83 Weslev H. Bradley, M.D. 1958 Ralph A. Ftnton, M.D. 198t1 Brr:n n Farrior, M.D. 1951 Julius Lempert, M"D. 1985 Bruce Proctor, M.D. 1962 Philip N4eltzer, M.D. 1986 Merle Lawrence, Ph.D. 1963l{illiam }. McNally, Vl.}" 1987 Robert M" Seyfarth" Ph.D. 1964 Kenneih M. L)ay, M.D. 1988 C. Deklc Tavlor, M.D. .1965 Senator ]oseph Sullivan, M.ll 1989 Eugene L" Derlacki, M.D. 1956 Dran M. Lierle, M.D. 1990l4Iilliam F. House, M"I). 1967 Lawrence R. Boies, M.D. 1991 Michael E. Classcock ]11, M.D. 1968 Sir Terence Cawthorne 1992 Willia:n H. Hitsclbcrger:, M"D. 1969 G*rdon l). Hoople, M.L). 1993 n. Th;rne I{" Cody, M"D., Ph.D. 1970john R. Lindsay, hil.D. 1994 Cesar Fcrnanrler, M.D. 197I F.. Glen Wever, Ph.D. 1995 Richard Ii.. (lac-r:k, M.D. 1972lrank D. Lathrop, M.D. 1996Jamers 1.. Sheehy, M.D. 1973 Moses H. Luri*, M.D. 1997 Mansfield F. W. Smith, M.D., M.5. 1974 Harry Rosenwasser, M.D. 1998 Robert A. )ahrsdoerfer, M.D. 1975 ]ohn E. Bordley, M.D" 1999 Barhara A. Bohne, Ph.D. 1976 Ben H. Senturia, lr{.D. 2000 Derald E" Brackmanr-r, M.D" 1977 Henry B. Perlman, M"l). SCIENTIFIC SESSIONS 2OOO PRTSIDINTIAL ADDRESS Ci;od afternoon, and w*lcome to ihe 133rd An- nual Meeting ol t1"re Otoi*gical Society. The first part of the progr.rm offers 1ros1 Presiden* an oppor- tunity to w;rx a i:it philosophical, antl that is what I wil1do. I r,r,ill begin with some remarks that will, { hope, pul things togeiher for us as to where we ar€ and whal l thirrk we can do to make some prllgress. M1r grandfather: used to tcll me lhat krrowing some- thing is rvrong crcatcs a ploblem. The problerrr is saying it or-rt loud. The problen:r, sut loud, is that medicine has coilided hend on with its moment in history. it is a profession in crisis" Physicians have lost the meaning to the system. Da3akey 1"ras rernincled us that irr the lasi 10-15 years, the systern has been sub.iected to the imperi- ous intrnsion of sell-appoinlcd o\rerseers of health carc reform, the theorists. The thenrisis have lim- iled or no clinical experience, have nol participated txtensively in patient care, have cvolved only a concept of managed care, and har.e used medical theory lr trake medical decision policy at a set phy- panies sirift costs to employees. The tanks of tl":e sician compensaiion-all based on a hlrpothesis. As uninsured will sivell" Put simply, the counlry has a rosult, medicine has undergone the mosi signifi- ceased to exalt pro{rssional achievement*un1*ss, o{ cant reprioritization of pr:inciples in its hislorv" course/ it is exhibited by a proiessional athlete, a Controi of medicine and l-reaith care has laketn a :novie star, or a corporate executirre. Managed care back seat to trusjness; thc mr:ney changers are arlvocates cortinue to argr-re that costs must be cut clearly ruling the ternptre. by decreasing physicians' sala:ies; thev have eni-11"1- As a mellical comrnunity, we are left surr.evinil ciated a prefetred place in health care for the gen- thu w'reckage of urhat lves once the Lrest meclical eralist, and simultaneously they have worked out a syster:n in the w'olld" In adciition, tht: public has redistribution of income to attract generalists. Not figured oul that matnaged care is discounted fee lor surprisingly, patients are in open revolt, criticaliy service, rationing, or service denial, and that some* assessing every a$pect of care. thing is dreadfully wrong. Our situalion is this; Quite simply, x /e are dealing with a new kind of Costs are increasing after a hiatus due to managed patient" Secause of the grealer availability of infor- care, a health care crisis for ernployers is loorning, mation and the abuses consequent on managed and health care spending is about to take off in a care, the attitude of the new patienl is different. tiglri labclr market as the $olrernment ma:rdates in- There is a trend tnlrrard patient emp$werment, as creased btlnefils and HMOs face increased account- lhe systern regularlv acts to erode palient irust in ability. Business will struggle to manage costs to itseli aad i;r doctors" There is an advocacy Sap retain w'orkers by qrrality :insurance options" lvhose horizons are unknowr:r. The economic, legis- This crisis will likely cor:re lo a head with the next lative, and strategic upheavals of the past decade economic slowdo,ivn, as small cornpanies opt oul nf have marginalized the fundamental work of pl-rysi- providing insurance to employees and large ceim- cians*to deliver health care-and hav* posiiioned virtually evr:rv l'reirlth care pro{essional as n pos- ness to expres$ and act upon what we each kncr,r, sible victirn of an attitude of hopelessless that abouL righf and wrong. could per:vade the entire svstell:l i'le or shc influ- A11 gr:cat battles are a series of scrimmages, and ences. scrimmagcs are won *r lost by the actious of ir"rdi- The public has cvolved to accept the generalist as rridr:als. As a cr:lture, rt,e harre become far too el- a carcgir.er for pnrposes o{ prevention and minor an-roreil of govemment of a social, and a profes- medical monitoring" Oncc sick, hor,r,etrer, the public sional groLlp sophistication cerrtralized to cr-lre a11 of dem;rnds the aitcntion of a wcli-lr:ained specialisl. our problems for us. ln point of fatl, hotvever, a Patientg simply l,vant us tc treat thcm, and they profession, iike socicty, catr {lourjsh only whcn the have rejectcd the hick for the genr:ralist model. Ac- nuclear r-rnit*tlre physiciarr-is secure. Change cr:ss to care is a toothSr issue. Marketplace compo- clearly is required to achieve tl"lat security to in- tition and thc dvnan-lics of managed care have spire. Changr: is intc11*ctual. Ch,lnge is s1ow, br-rt it stifled the specialist community and the procedurc- cantl$t be too slow, or lhe individual irrspir:ation oriented sr.rbspecialties. becomes bogged dor,vn, peptic antl curservative- Organizrd practitioners of auditdogy have in sev- witness the Chicago CuLrs irr the 90th year of iheir eral ways ini'licated their: dilsire to erpand their rebuiltlir"rg eifort. Ceorge Will has sr-rggesled a con- scope of practice to achi*r,e r:rrregulated acccss to cept of change tl"rat I like. fle talks aboui changing patients, illong lhe lincs r>f the opton"letry modei. one bv one, from thc irrside out. Cha:rge th;rt is The theorists cnr:renilv mangling health care r,',olt1d achi*rred by living tl-re littorals, with big conse- grant audiologists unrergrriated acc€ss to palients, quences. Furtlrermorr:, unwritten rules arc more direct rein"rbursen:ieirt for sen ices, and membetrship important than thos* written. T'he lalter we violatet, on physician panels. Ilhvsici"rn coaliiious, on the with or without trifling con$equellces. The unwrit- other hand, ilre proaclivcly proposing comprehcn- ten rules, when brr:ken, disrespect the prclfession sive p*sitions cn hcairing lrei-rlth carc that errsure the tlrat gavc rise to thenr and disgrace their perpctra- primacv of the physician. A rerrlinder to r-rs a11 that tor. Al alr cxample, a prime concern to n-rc that medical diagnosis shr:r"rld not bt confu$ed N,ith me- roprcsorlts one of tllose many p*ints at which tt: chanical tasks or witli tlre legislative pr:ocess. 'Ihe bcgir: the chanS;c and ihat tonstitutes as u/ell one of lines in ihe sanr"1 har.e been clearly dratn, as wo as those counterintr.ritir.e places io thich some have specialists r:eject tl-re cooperative organ.ization thaL ireen driven is n sporadically appearing trend ir-r elab*ratcs fi c()rnmon messagr and that rcdelincs r"leurotr;logy to ai:andon ti-re cor:peration between LlS anO tnem. otologists and neurosurgcon$ in acoustic nellronla Here is my per$pcctir.,e: As thls sitr-lalicn b*gins $urgery. to unfoid, health care is brcken, and employers, From time to time I am macle freslrly nwnre of employees, patients, and the goveLnrnent are that. hleurotolagists have operated on acoustic tu- bror-rght to a stalcmtrte relatirre to the increasingly mors with the inpr-lt, expertise, and support of our "I"his org;anizerl medicai pre$t:nce. 1f the stalemate is not pa,:tncrs for better than 40 years. coopr::ration, resolved, lheln, as lJvi Tleinholt l"ias cautioned, \,\re I su5;gest, forms one of thast unr,vritten micro-rules may find ourselves the medical analogue nf a rale* of pri:fessiorral behavior, thr: vioiation of which can regr"rlated utility. As one oi my fat'orite philoso- have huge corsequences. This battle was met, en* phers has declared, predicting the future just isn't dr:rtld, and u,on by ili1l l{ouse, ancl cast in stone by rl,'hat it usetl to be. I drln't know .how tl"ris is going thi: exccllence exhibited bv his succceding teairts. to end. But on this occasion 1 woukl like to sugsest Cooperuiion betr,veen neurertology anctr neurosur- a beginning. gcry exists because it is te leologlcallv right. It un- The circumstances in which we lirrd rlurselv€s it'l derwrites cxcc11*nce" Once we disavow it, w* are medicinc are cosmically uninspiring. In pulsurt of hft to considrr mediocrity*ar:d in s* doing goner- professional and emotional prospcr:ity, we can bt ate mediocrity as an optiorr. dr^iven to counter:intr-ritive places ;:nd soltitions wt: For years, otologists criticiztrd nellrosurgeons might not othenvise resort to. Our re$ponses cannot who operated inclependenily as irresponsible. lt ap- be arrtisocial. We must crcate sornething thal en- pears illogical and recidivistic to abandon the team richcs us all. lnstc'ad of jnhabiiing those counterin- concept. I can hear the ner-irosurgerms now as they tuitiirc places, wc nrust spend l.'nore ti;nc in cre;rtir.s toss back their accrrsations. But lhe one accusation placcs, effecting ch;rngc. Change l-realr progress; that we must shoulder, lhe one nccusation based in prosress is changed rvitl-r a pur L)$se. Change for tl're facl, is lhat nre simply cnnnot care for al1 of our l:etter, hou,er,er, cal olrlv ]:e achierred thrttligh in- potential complications. lerl"raps some practilioncrs 'becrnre divirlu,'rl r:esponsibility*that is, through a rn,illir-rg- too comfortable in ihc danger zone of thc 2 posterior cranial fossa by virtue of repeated success. of heallh care, noi because of some dernand from ircriraps they have been driven to consider a coun- the theorists. It shnuld not be rnodi{ied by nor con- lerintuitirre position for convenience Lrecause of sumed within the records we know now as man- hospital dynamics or politics, or because coopera- aged care. This eiegantly derived concept cannot be tion has becn made irnpossilrle 1:y, managed care allowed to be aberrated by the theorists who cannot shibbolcths" l-he fact is, sorne form of learn ap- and will not understand ahe caring cooperation thal proach to ;rcoustic tumor snrgery corrstitutes the is cost-effective. Excellence enriches us a1i" Excel- stalrdar:d in most commurrities. lence is inspiring, and inspiration can dissipate "Ihe new patient is discrimjnatir"rg and infornred. some of the hopeless::ess that afflicts lhe entire Neurosurgeons now understand it. Not a week medical system. Ladies and gentleman, the ghosts goes by in which a neurosurseon doesn't call me of greatness that inhabit this society, this profes- and say, "I couid do this proceefuire but I don't have sion, and every one of us wouldn't have it any other a neurotologist." My heart leaps wher"r thcy tell me way. So please, effect thc change, inspire by excel- that. lt prorrides care of excellence. The tradition of lence, and remernber lhe unwritten srnall rules with cooperation has been forged in ihe biood, sweat, big consequ*ncesr do the work" It is an individual and tears of our predecessors, on the shoulders of prerogative. It begins with each one of us. And their pallents. It has comt: about through the scicncc good luck. lt isn't going to be easv. Thank you. INTRODUCTION OF CUTST OF HONOR: DTRALD E. BRACKMANN, M.D. C. Cnry lnckson, M.D. It ls nrith Sreat pleasure that i introduce i)r. Der- among the finest otologists in the world. Like fine ald E" I3rackmann, the 2000 American Otological artists, we microsul'geons are .ommonly accused of Society's Cuest t.rf i'loncx. I* 197A, npon completion consigning our souls to our profession, at great cost of his trainirrg at the University of Southern Cali- to our personal lives. In contradistinction to this fornia, Dr. Brackman:r ioined the House Ear Clinic, stereotype, Derald has maintained a lralanced and of which he is now president. He has led tire spe- capacious life. Wilh Char, his lovely wife of 41 cialty from his pr:st as president of the world's lead- years, he has fouL sons, two grandchildren, and a ing socielies, including lhe American Neurotology wor-rder:ful family. He is an avid sportsman. lf he's $ociety, the An"rerican Academy of Otolaryng;o1o- not on his troat fishing with his sons, he might be gy-Heacl ancl Neck Surgery, and the |,J<;rth Ameri- found hunting in the field. Although I cair't vouch can Skull Base Society" Most natably he is past for the company he keeps, il is appropriale and just president of the Anerican Oblogical Serciety. Dr" that the senior society acknolt,ledge his continuing Brackmann has contribr"rted over 260 scientific pa- service to the AO5, and more brnadly to the aca- pers and book chapter$ to the literature and has clemic and clinical domains of i:tology and neu- edited or co-edited nunrcrous books. Fle is a rotology. I proudly introduce Derald E. Brackmann sought-after guest speaker the world over, and his as the Cuest of Honor for the 133rd Annual Meet- list of honors and awards is awe-inspiring. He is ing of the Otological Society. RIMARKS OI CUEST OF HONOR Dernld E. Brntkmann, M.D. Cary and l had not rcl'renrsed at all. I didn't know a few remarks, and I will kerp lhem brief. As Cary what l-re was going to ialk about. I had prepared just has just described, many outside forces are impact- ing on our enjovment of our practice. 13r-rt tr prcscnt and al lhe same time get lhe great personai salis- to you that nr:vertheless, medicine*arrd I n,iltr be fi"lction that we all feel, the hug; anrl all the ihings e\r*n mor* specific and sa1, otol0gy-is the greatest that yor"r all experience as I do? tr'r,e been very for- profcssion in the world. Whele else can vou make a tunate that rarhen I go to bed Sr"rnday r"right 1 carr'i decent livir"lg (ant1 r've're a1[ goilrg to nrake a clecent wail t* get up Monday morning and go to r,v*rk. livingl)*rvherel else cafl vor.l do that, help pe,:ple, How lucky it is to be able to go ll"rrouglr life and do thatl Cary rnentioned that Jerns Thompson crxr- cluded a ta}k as the guest of honor at the ANS h,v slrr:wing a sJide saying that heing guest of honor is the begirning of tlre errctr. Of colrrse, I can ;rlways point to Horrn,ard, who w'as guest of lrtxror: ,10 ;rears ago, and the urd is now'herr: in sight for him, so I :t,'on't take it as al1 had. When you do get to this stage, you have a liltle bit of license to be philo- sophical. {Dr" Brockwann shor;,:s a slid* rttling, "The ruL>r:s': tlor1 fishing is ltatter lh{t.rt tk brst tl*t7 utorhing""} As Cary saiel, r,r,hi1e you are going througli all of this, and no matter how much lou lorre your work, never forSel that slide. 3o gu fishirrg, and take your kids with vou. It's the greatest thing you can do for them" 'T'hank you" Dr. Jaekson: On this or-'casionr Derald, ailow me ti: present you wilh tlris cer:tilicate to commemorate it, and thank you" Dr" Srackrnann; Thank you so much, Cary. PRISENTATION Of PRESIDTNTIAL CITATIOI'{: WILLIAM B. wtLLIAMS, rSQ" C. Carw ]*ckson,44.D. I next have the plcasure of awarding n presidcn- tial cit;rtion. William B. Williams joineri his Iatl-rer- in-1aw', Harry Treece, at }iichard's Medical nearly 30 years ago. Since then he has represented mul- tiple companies that impact otology. 1t is, hr:weverr, not therse companies but the man.l wish to citr:. For 30 years, Bill has represenled a capacity to serve this specialty in a mann.)r that, l:ut for the hkes of Jack Urban, is virtuallv unparalleled. His simple, honest, and straightforn ard di;rlogue with cloctors for 30 years has made him a trusted col.leaguc at the ready to serve production, innovation, acadernic in- terci-range, and an old school collegiality that has enriched otoiogy scieniiiic congresses for decades. It is thereforr my privilege and great pleasure to present ihis plesiderrtial citation to acknowledge tlre ongoing cfireer of service to otoiogy to Mr" William B. Wiiiialns, rnv dear friend. Allow me, 8i11, to pre$enl you with ihis certificate in com- rnt,mor,rtion oI thi> (j((,lsi()lI. RESPONST OF PRTSIDENTIAL CITATION RTCIPIENT \Nillinm B. Williarns, Es{" Thank you, sir. l'd like to thank Dr" jackson" I'd on this thing 28 yt:ars ago. Dr" Jacks*n, Dr. llrack- .like to thank Mr. Har:ry Treece for starting me off in mann, and l)r. Owens keep me going. Thanks to ail this business, anel I'd like to thank the two gentle- nf tlre otologists who havc macle it a wor"rder{ul man, Dr. l]ev A::mstror:g and Dr. Ed Stevenson, career/ and to my wife for letting me ily all over tho who carne dor,r,n here because they pushecl me off world and making it go. Thank you. TRANSACTIONS 2OOO / AMERICAN OTOLOCICAL SOCIETY FTLINT IMMUNODEIIC NCY VIRUS*MEDIATED CENI THERAPY OT MIDDLE TAR MUCOSA CILLS Hnrnid R. Djatilian, M.D,, Ynsultit'oxTsuboi, M,D., W*1e17 Ohritsch, and lizhnt Lin, M.D. ABSTRACT Hypothesis: To investigate the feasibility of gene therapy of the n"riddle ear rlluco$a using a :rovel vector" Background: lnsofar as presenl medications are inadeqate to address chror:ic otitis merjia, cholesteatonra, or tyrrrpanic membrane ;:erforation, newer melh- orJs of treatmEnt for these diseases, such as gene therapy, need be explored. Cenes cor-rld be usecl to alter cytokines irr thtl middle ear, slcw or stop choles- teatoma growth, or improve tyrnpanic menrbrane perforation healirrg. Fellintl immunodeficiency virus (FlV), a new lentiviral vecior, has heen found to have grerate r ihan 9Clol, e{ficacy in transfecting epithelial cells. Thereiore, in vivo gene therapy of midrJle ear mucosal cells was attempted. Methods: Twenty microliters of 107 vectr:rs/mL FIV carrying the gene ior green flur:rescence protein (CFP) was introduced into the middle ears of Sprague-Dawley, rats via a Liulla approach. R.esults: [xpression oi the CFP gene was observed in the nricldle ear n:ucersal cells, indicating transfection. Conclusion: Cene tlrerapy of the nriddle ear is ieasible and has a potential human application in treatirrg pationts with chror-ric olitis n:eclia. cholestealo- ma, or tympanic menrbrane per{oration. Reprint requests: Jizhen Lin, M.l)., Ilox 396 Uh4HC, 420 S.E" Delaware Street, Minne- apolis, MI\ 55455; ph. 612-624-5059; {ax 612-625-2101. E-mail; linxx004@ maroon"tc.umn.edu TRAI\SACTIONS 2OI}O / AMTRICAN OTOLOCICAL SOCIITY ANALYSIS OF THT DYSFUNCTIONAL ETJSTACHIAN TUBE BY VINEO TNDOSCOPY Dtnnis S. Poe, M.D., Aslwaf A. Halnwn, M"B,B.Ch., M.5., nnd Osams A. Razek, M.B,B.Ch., M"S. ABSTRACT Objective: Human eustar:hian tubes (ETs) with lcnown ear pathology were inspected endoscopically and video recordings were made for slow-motiorr analysis of pathophysiology. Setting: Ambulatory office in a tertiary referral center. $ubjects: Forty-four adults with 64 pathological ears" lnterventians: Transn;lsal endoscopic examination of the nasoplraryngeal opening of the ET during rest, swallowing, and yawning tc stLrdy ET dilatory move ments. Main outcome Measures: Slow-motion video analysis of ET opening nlove- ments" Results: Sixty-four pathological ears and ETs ltere studied. Tubal {r,rnction was gracled on: I . [xtent of lateral excursion and progression of dilatory wave as estimates oi tensor veli palatini arrd dilator tubae muscle iunction. Reduced funciion was observed in 43 tubes. 2. Degrce of mucosal disease, which was significant in 48 tubes. 3. Polypoid or other obstructive mucosal changes, present in l5 tubes. 4. Ease and {requency of tubal operring with maneuvers: 26 tubes opened moderately, 21 opened minimally, and 11 were unable to open" 5. Patulous tubes. All 6 clinically patulous tubes showed conc;:rvities in the superior third oi the tube, which is convex in normals. All tul:es with active ear palhology (otitis rnedia with effusion, tympanic membr;rne retractiot-t, drairring ear, cholesteatonra) had significant ahrrormali- ties. Correlation could not be rnade between the severity of middle ear disease and the severity of observed ET dysfunction. Conclusions: Slow-motion endoscopic video analysis was a useful techr:ique in classifying typos of ET pathology. Additiorral str-rdies of dysfunctional tr,rbes are needed to predici outconres irr operative ear cases and to design intratubal therapy for chronically dysfunctional tuhes. Reprint requests: Dennis S. Poe, M.D., Zero Hmerson Place, Suite 2C, Boston, MA AZfi 4; yh, 617 -7 25-3300; fax 677 -725-27q7 . H-mail; [email protected] TIANSACTIONS 2OI}O / AMTRICAN OTOLOCICAL SOCITTY LASTR STAPTDOTOMY WITH CONSIRVATION OF THE STAPEDIAL TTN DON Railney C. Perkins, M.D. ABSTRACT Olriective: The objective of this study was to develop a procedure that allows the siapedial tendon to l-:e conserved in the surgical correction of otosclerosis, and to assess the results. Conservation of the tendon theoretically should prcl- vide protection against noise trauma in this group of patients. Study Design: Patients in wlrom the proceclure was done were studiecl pro- sp*ctively. Setting: Surgery was performed in an ambulatory surgical center, with pre- and postoperative studies dorre in an outpatient clinic. Patients: Patients who had clinical o{osclerosis and who were c:rndidates for silrgery were selecled for the study. lnterventions: Patients in the study group underwent laser stapedotonry with conservation of the stapedial tendorr. The procedures were done under local analgesia on an outpatient basis" Main Outcome Measures: Audiometric improvement in hearing and main- tenance of stapedial reflex on impedarrce aurliometry were assessed. Air con- duction, bone conduction, and speech discrimination testing and impedance audiometry were per{ormed pre- and postopelatively. Results: Audiometric resLllts were comparable with results in contrr:l patients who had undergone conventional laser stapedotomy with vaporizalion oi the stapedial tendon. The stapedial reflex could be demnnstraied postoperatively in the study group. Tl'rere rl,as no evidence o{ adverse effect, increasecJ cost, or significantly increased surgical tirne, and there was no increase in morbidity. Conclusion: The technique provides a method for conserving the stapedial tendon in patients undergoing laser stapedotomy for atosclerosis. ln these pa- tients it is expectecl that ihe protective function of the stapedial reflex will be maintained. Reprint requests: ltodney C. Perkins, M.D., CA Ear Instituie, 801 Welch ]td., Palo Alto, CA 94304-1611; ph. 650-494-1000; fax 550-323-2365. TRANSACTTONS 2000 / AMT&ICAN OTO|"OC|CAL SOC|;Ty CURRHNT USE OT IMPLANTS IN MIDDLE IAR SURCTRY Robert A. Coldenberg, M.D., nnd lolm R. Emmett, M.D., F.4"C.5. ABSTRACT Hypothesis (Obiective): Members r:f the Anrerican Otological Scciety (AOS) anrJ Amerir:an l''leurotology Society (Al\S) w Reprini requests: Robert A. Coldenbe:g, M.D., 1il W. First Skeet, Suite 600, Dayton, OH 15407; ph. 937-228-2403; t ax 937 -223 -9297. E -mail : robert. [email protected] u DISCUSSION DISCUSSION PERIOD l: hrllDDLI EAR/MASTOID Pape rs 1*4 Dr. C. Gary Jackson (1rJas1"nri11e, TTd): Thesr pa- cleft palate, the muscies are attached puorly, and pers are n$w operl for discussion. llrerefore the function o{ the two muscles varies. Dr. ]ohn Shea, ]r. (Memphis, TI{): } congratr.rlatc There is a gradient*l have prrblished on this toplc Dr. Poe for tl"ris excellent prescntaiion. It is implrr- Lrefore. 1 thi* that what has to be shrwn is tl'ris type tant wnrk thai teaches us what is going on in the of dysfunction wiih relation to the anatomy of the eustachian tubr:, sornething I a:n fascinated l,r,'iih. i nasal pharynx and cleft palate in particular" That certainly want to come se€ I)r. Poe's work and be- will be revealing irr trying to determine ihe etiology gin to do it mvself. It is rcally I)r. Pcrkins's paper of eust;:chian tr-rbe ma llunction. that I want to comment on" I applaud the facl that Dr. ]ackson: Thank you. Ceorge? he has used vein interposition in a cicver way. Rod Dr. George Lesinski (Cincinnati, OH): I wish to has allvays been a very clerrer person, and I con- echo Dr. Shea's comments rcgarding Dr" Irerkins's gratulate him. At the American Otological Society vcry elegant and meticulous surgery. Tht physics meetlng last year Dr. Causse presentecl a series of would nr:t allow a sound protection mechanlsm papers on preserving the stapedir:s tendon. As you lrom lhe stapedius tendon, at least as I undersland know, we are physicians, practitioner:s of physics, it. I would like to comment further. We have an and the physics o{ the ear are that t}'re stapedir-rs ongoing study that now comprises in excess of 300 tendon cr:ntracts the stapcs in the oval window stapedectomy rerrisions undertaken because of arnd is jammed in there, and unless you preserve the hearing failure; irr 78'll, *f those paiients the proce- $tapes {ootplate in the oval windorv, there is no dure failed becausr the prosthesis migraled out of leason to preserve the stapes ten 10 DISCUSSION Dr" Jack Pulec (Los Angeles, CA): I wish to com- dial reflex. When they tried to measure i:rcus morre- pliment Dr. Poe on the quality of his photographs ment and maller-rs movement, they didn't get that. I and video recording. This is a very technically dif- believe that is true, and probably because there is a ficult thing to accomplish. I was vetv pleased to stapes there. One miglrt speculate that if there were see )r. lloe's work; it is one of the first times in a no stapes footplate attached io that, would part ol long time that we have seen great interesi and prog- that be damaging to the incus. i submit that prob- ress in this area. Very few people can even make ably some of it would, but that is not the way it is the diagnosis of an abnormally patent eustachian mediated in the normal siluation. tube. Ii is a severely missed or undiagnosed prob- One of the things I'd like to do before I forget a lem. I'm certain Dr. Poe's ma.ior accornplishment Eecond time is to thank my co-authors, lvho werr here is the technique, the details of what causes not mentioned on the slide: Dr. Catrina Stidern, serous or chronic otitis media, a totally different who is a le11ow with us aad is goi:-rg inlo praciice in pari of this stutly. With a thin, atrophic mucous Caiifornia, and Dr. Yoon, who helped prepare the membrane, ihe fat does lencl to show through; in pape:. many cases the fat is missing, so that is part of the Witlr rcgard to Dr:. l.esinski's comments, I agree problern as we1l. I ccngratulate you, Dr. l?or:, and with Dr. Shea ihat the vein seal in the fenestra is remind the audience what a greai series o{ pictures imporlant, and I know Dr. Causse has also cham- those were. pionecl tlris. I also agree, though, with Dr. Lesinski Dr. Rodney C. Serkins (Palo Alto, CA): i would that the method by which the preisthesis ejects is like io comment on Dr. Shea's and Dr. l,esinski's probably the tightening of a vein under the piston. comments. As Dr. Sl"rea pointec1 out, we have no It's the same mechanism by which a tympanic evidence that ihis is protective over the long mn. I membrane will lateralize if it is cup-shaped when it didn't :nake any ciain"r for that, and I dr:rn't t.hink is put in. It contracls, and there is no for:ce on it any claim should be made. The best recent work on pulling out. this topic has been done at M1T, by Pang, Peak, a:rd In the first few hundred lase: stapecloion:iies Cil1ia::r. They have shown that the effeci of the sta- we used a blood seal and it iarorked quite wel1, pes refiex js mediated through a stif{ening of the so I lrelievc others would fi:rd it works fine as well. annular li5;ament. This a11ows the low-frequency I expect we will continue the stutly in a little more masking to be decreased, and hearing is better detail with audiometric sludies o{ sountl and in the high frequencies. They also found that the noise, and I hope we will have a frrrther report stapes was the only lhing lhat morred in the stape- later. 1t TRANSACTIONS zOCIO / AMERICAN CITOLOCICAL SOCITTY VIBRATORY SAMPLE MACNTTOMETRY OF STAPIS PROSTHHSES TO ASSESS MR SAFETY AND COMPATIBILITY Mark l. Sqws, M.D., {}nil Dercick W. Peterman, Pfu.D. ABSTRACT Objective: To assess lhe ferrcmagnetiviiy of stapes prustheses using a vihra- tory sanrple nragnetometer {VSM)" Data Sources: Previr:usly, stapers prostheses from different manu{aclurers were placed in a 1 "5-tesia MRI field to determine their ferromagnetic properiies. Two series of Xonred prostheses were lound to be {erromagnetic. VSM was performed on I6 samples, inclr-:ding ferromagnetic 420F siainless steel. VSM testing was performed using an LDJ model 9600 VSM, in accordance with American Society for Testirrg anrJ Materials standard ,4894. Results: A VSM measures lhe magnetic dipole moment o{ a sample in a magnetic fielcl. The magnetic iield is swept over a range o{ magnetic fie ids, and tl"re magnetic dipole moment is plotted as a functiorr of field. ln a ferromagnetic material, the dipole mcment plat demonstrates hysteresis. The samples made with 3l6L stainless steel, wlrich is used irr otological implants, are fairly non- magnetic relative lo the 420F stairrless stee l. The torque and linear force cln the prosthesis in a given magnetic field can be calculated irom the results o{ VSM. Conclusion: On VSM, prorthe:es made with 3l6L slainless steel were rela* tively nonferromagnstic when r:onrpared with 420! stainless steel. The forees acting on a prosthesis in a given magnetic field can be calculated using VSM" The saiety oi performing MRI in patients with these implants needs to be reas- sessed. Reprint requests: Mark J. Syms, M"D., Otolaryngology*Head ancl lrJeck $urgery, Tripler Regional Medical Center, Htxolulu, HI 96859-5000; ph. 808-433-3185; fax 808-433"9033. E-mail: [email protected] 12 TRANSACTIONS 2OOO / AMERICAN OTOLOCICAL SOCIETY MIDDLE IAR PROSTHISIS DISPLACTMINT IN HICH STRENCTH MACNTTIC FIILDS Michelle D. Williarns, M.5.4, Pntrickl. Antanelli, M.D., r.A.C.S., nn.d LaynaWilliarns, M.D. ABSTRACT Hypothesis: Middle ear prostheses made from nonnragnetic, magnetic reso- ilance (MR)-compatible metals reportedly displace ex vivo in the presence of high magnetic fields used in MR imaging. we postuiated that the prosthesis displacement seen with nonmagnetic, MR-compatible prostheses ex vivo may not be clinically significant in vivo. Methods: Middle ear prostheses made from ferromagnetic (420f stainless steel) and ilonmagnetic MR-compatible metals {3161 siainless steel and plati- num) were examined ior magnetic field inieractions at 4.2 tesla (T)" Ix vivc: testing corrsisted o{ measurements of the translational and rotational motion of the prosthesis irrduced by lhe static magnetic field. ln vivo testing entailed implanting prostheses in cadaveric temporal bones and performing clinical MR sequences. Prosthesis d isplacement was measu red sem iquanti tativeiy. Results: Angular dellection was observed in all samples made from nonmag- netic stainless steel^ The negative control (platinum) demonstrated ncl de{lec- lion, and the positive controls (feromagnelic stainless steel) deflected more than 90 degrees. Torque analysis showed movement in five of five nonmagnetic stainless sleel prostheses. Prostheses made from nonmagneiic stainless steel remained in place without appreciable lor:sening in vivo following MR inrag- ir"r6. Prostheses macie with known ferromagnetic properties were displaced at 4.7 T ht;l not at 1.5 T. Conclusion: Middle ear prostheses nrade from low-magnetic stainless steel do move in the presence of high magnetic fields ex vivo; however, this does not appear to be clinically or statistically significant in vivo at 4"v T. MR imaging shauld be undertaken with caution in individuals with prostheses macJe from slainless steel with strong ferromagnetic properties. Reprint requests: Patrick J. Antonelli, M.D", F.A"C.S., Department of Otolaryngology, University of Florida Heaith Science Center, Box 100254, JHMHC, Cainesviile, FL 32610-0264; ph. 352-392-4461 ; fa x 352-392 -67 81. 1J TRANSACTIONS 2OOO I AMTR:CAN OTOLOC:CAL SOCIETY PROCNOSTIC FACTORS IN O55:CULOPLA$TY: A STATISTICAL STACINC SYSTEM lohn L. Dornhoffer, M"D., rtnil Edrusrd K. Cardner, M.D. ABSTRACT Objective: To determine {actors that predict hearing results using a standard prosthesis system. Study Design: Retrospective chart revierv. Setting: Tertiary referral center. Patients: All palients undergoing ossiculr:plasiy wiih the Dornhoffer HAPEX Partial and Total Ossicular Replacement Prostheses (PORP and TORF) from .1999 Iebruary 1!]95 to May who had docLrmenled postoperaiive follow-up and .105 no congenital atresia or stapes fixatiorr. A total of 185 patients (200 ears), men and B0 r,vomen, were evalualed. lntervention{s): Ossiculoplasty with the Dornhoffer prostheses. Main Outcome Measure(s): Hearing resulls using a four-frequency pure-tone average air-bone gap (PTA-ABC) were measured. Mullivariale statistical analy- sis cjetermined the efiect of nrucosal status, ossicular thain status, and type of reconstructiorr techniques on hearing. Results: PTA-ABCs r,r,ere 1 3.4 t 8.1 dB and 1 4,0 t 8.4 for the PORPs (rr * 1 1 4) and TORPs (n = B6), respectively, which was not slatistically different. When the malleus handle was present (n = 125), lhe PTA-ABC was 1 1.6 t 6.2 dB, "16.9 .1il.1 compared to t dB when it was ai:senl ln = 74), which was staiistically significant (P <0"05). Mucr:sal fibrosis, drainage, revision ear surgery, and type af surgical procedure had a significanl detrintental impact on hearing. The type oi pathnlogy (perforation versus cholesteatoma) had no significant inrpact on hearing results. Conclusions: Tlre revised staging system, the Ossiculoplasty Outcome Pa- rameter Stagirrg (OOPS) lnclex, nrore arlequately precJicts hearing oulcome in our series af 200 cases. Reprint rr:quesls: john L. Dornho{{er, M.D., Department of Otolaryngr:it"rgy, lJniversity of Arkansas for Medical Sciences, 4301 West Markham Slot 543, Li::le Rock, AR 7 22A5. E-mail: Dornhoff erlohn [email protected] 14 DISCUSSION DISCUSSION PERIOD ll: MIDDLE EAR/MASTOID Papers 5*7 Dr. C. Gary ]ackson (Nashville, TNI): This series me they would do an MRl sludy in a patient wilh a of papers is now open for discussion. one-sicled stapeciectomy but not in patients with Oats (United Kir-rgdom): Our racliologists are bilateral stapedeclomies, so I wor-rld like some guid- worr'ied about the possibiiity of heating the pros- ancc as r,vel}. thcsis in an MR field. Can you address that issur:? Dr" Rick Chole (51. Louis, M()): Perhaps this is an Dr" Mark Syms (Honolulu, HI): They're right. unfair question to ask in the current medicolegal Heating is a big concern, and as the fjelds get stron- environment, trut has anyon€l here *ver had a sta- ger, it will become an even bigger concern. 1t js not pedectomy patient witl"i a serious con:rplication be- just gross displacement of the prostlresis that will cause of an MR machine? be a concern but the very sma1l, quick, back-and- Dr. ]ackson: Can we lrarre a shi:w of hands from {orth moven-rents. One o{ the problems with a sta- any wlro lrarre? (No kmds utere u1t.) pes prosthesis is that the FDA considers it a static Dr. Chole: I thirrk that preity well answ,ers the implanl, similar to an aneurysm clip, in terms of question. I l'rate io be rrnscientific ahout it, but. . . . evaluation. But it is actually meant lo rnove, so it is Dr. Syms: Actually" there are two issues. One a uniqr-re implant, di{ferent from other kinds of rne- is that mr:st people are currently using 1"5-T' Ml{ taliic implants. fields, and the scanners are getting stron6;er. The Michelle l,t/illiams {Cainsville, TX): Previor_rs bor"rtiqr:re scanners use 3-T magnetic fields, and in siudies done on small prostheses hal,e indicated no Creai Britai::r 8-T machines are being tesled. The heating when thc prostheses were subiected to iong problem is not rtrhether they are safe now. lrnl trials r,r,'ithin an MII machine, nor was there any whether thery will he safe 20 years {rom now magnetism induced j.l"t the sma11 prostheses. There wheln patierlt$ are unclergoing this type of evalua- have been no reports of vertigo ir-r patients with tion. middie ear prostheses, as might occur if there was The FDA has a working paprr asking that the heating within the middle ear. safety of the prosthesis be specified within the mag, Dr" Charles Luetje (Kansas City, MO): I haver netic field in which it was tested. In other words, some practical concerns with regard to the migla- the d<-:cumentalion lras to ray, This prosthesis or iion of these metailic prosthetic devices. In the of- impiant can be safely scanned in a 1.5-T fielcl. li's a fice, not infrequently we are callecl $onr thc radi- working paper*the regrrlation hasn't been adopted ology dcprrtment. Thr: radir:logists say, rve need to yet:bul thai is the riirection the FDA is moving in harre data about thr implant yeru did on this patient with regard til certilication ol MR safety and cor:rl- (it's usually a stapedectomy)-do you have the num- patii:ility" ber or the catalog nurnbel, etc., because otherw-ise Dr" Dnug Backous (Seatlle. WA): I ihink we are we will not do the MRJ. I have lold the radiologists luoking at it Lrackwards. I r,vas cailed by a radiolo* to go ahead ancl do the study, il won't hur:t any- gist because a patient vr,ho underwent MRI of the thing. Maybe I shouldn't say it, but 1 do" Sometime_.s shouldcr had a stapes prosthesis and claimed fhat they want documentation and sometimes they her head heated up. As it turned out, she had two don't. I know that therer ale no catalog num.bers lelt or three psychiatric diagnoses, but when it came for certain oI the tantalum wire prostheses. I knon, time for: the attornelzs, the queslirln i\''as not wheth- some of the Robinson prostherse$ were molybde- er this proslhesis hertcd ilp er moved. It was 'fhe num, nickel, and so on. in virro studiets look proved to us that il didn't, but the problem is, that pretty good. Can I cor-rtinr-re to tell the radiologists can lead to a settlement, which leads to a p:ecedenl, not lo worry about ii? r,rrhich is a problenr, so wc exercise iots of caution. I Or. ]ackson: Somc of our radiologists harre told think it's very ambigrous. I5 PANTL DISCUSSION CHOLESTTATOMA: CANAL WALL UP, CANAL WALL DOWN? PANEL DISCUSSION I There trre several factors to be consid.ered. First is the physical parameters of ihe disease. Children of- pneumatized te:nporal boles with Moderatr:r: Bruce Cantz, lowa City, IA ten have well- deep cell tracks, and this can complicate complele Participants: Paul Lambert, Charleston, SC; ]oe Nado1, Boston, MA; and Slmon Parisier, l)llew York, disease removal. Adults mav have a sclerotic mas- }JY toid secondary to chiklhoeil infections. A second Ir. Bruce Cantzl May l intruduce }au1 Lambert, factor*and this may be the mcrst imporiant-is the from Charleston, South Carolina poor function of the eustachian tube in children, Dr. Paul Lambert: Thank you very much. I am which predispi:ses to oiitis media and secondarY delighted to be part of this panel as r've explore a infectlon of the cholesteatoma, thus promoling a subject th;rt continues to elicit as much cnntroversy more aggressive disease process" It also predisposes as it did when I began my training, nearly 25 years to retraction pockets, and thus recurrent disease. ago. As I present some thoughts on cholesteaton"ra Also to be considerecl is that the poiential for tissue surgeLy, my goals will be tlr"ofold: first, to discuss growth in children is greater lhan in adults, r\wi11S some con{epis regarding intact canal wall and ca- t* lhe normal elabor:alion of various growth fartors. nal-wall-down mastoidectomy, and second, to dis- Several yearc ago rn e published a series r:f pedi- cuss my experience w'ith these procedures in treat- atlic cholesteatomas" The average age wa$ 10 years. ing pedialric cholesteatomas. Follow-up lastr:d from 1 to 12.5 years (average, 3 The advantages of an intact canal wall procedure years). I prefer to perform an inttrct wall procedure are well recognized ar:id include preserrration of for all cholesteatermas, and in this particular ser:ies normal anatomy, faster healing, and fewe: long- nf children, it was the iniiial procedure in 70?1, of term care issues. An inlact canal wa1l procedure those needing a masloidectomy. Some patients also facllitales use of a hearing aid, which is olten rt ere treated r.vith middle ear exploration only. It is needed in this patienl group. There is a price to pay, also my practice to stage these earn, returning in howerrel, in the increased incidence of both re- 8*10 months to perform the ossiculoplas$r anri lo sidual and recurrent disease" lnadvertently leaving check for any residual distase. Even though the in- a small locus of squamous epithelir,rrn behind is a tent was to maintain the canal wal1 intact, almost distinct possibility, given the greater technical one in six patients dici need conversion lo a canal- problems with this procedure as well as the dimin- wall-dor.vn procedure, and 15% of the patients re- ished exposure. Maintaining tl"re canal tva11 intact quired a third procedure because r:{ persistent dis- provides spaces in r,vhich retractlons can occur, and ease. The overall incidence of residual and recur- thus also recurrent disease, This recidivism is not a rent disease was abuut 4}"lr, a figure consistent n ith trivial problem, particularly in children" what l:ras been pr"rblished in the liierature. In 19'L, ln contrast, removing; thc canal wal1 essentially discase was lefi intentionally*for example, around rliminates the problem of recurrent diseasc from an intact stapes that was to be removed in a second retraction pockets, and the improvecl exposure stage. In most of the patients with recurrent disease greatly lessens the incidence of residual disoase" the procedure was converted to a can;rl-wa11-rlown The accumulation o{ squamous debris and the pos- procedure. In patients initially treated with a canal- sibility cf infection, howevet, must always be l:orne wall-down procedure, staging tvas coillmon, and in mind, and hearing aid use can be mr:re problem- only one patient reqr"rired a third proccdure. In the atic. cana[-wa11-dort'n group, recutlent cholesteatoma The problerns of residual and recurrent disease from a retraciion pocket did not occur, and the rate are particularly important in children, in whom of residual cholesteatoma was only 12%. rales tend to be signilicantly higher than irr arltrlts- What about hearing? $ome believe that heirring Why is this? Is the hiology of a pediatric choleste- results are better when the canal wall is left intact; atoma so:rrehow differerrt? however, that is disputed in the literalure. Ii was 15 not our finding in ii:ris particular series. lnstead, fhe iechnique is very straightforw,ard: a postau- irearing depended more on whether lhere was an ricular incision is made, followed by the develop- intact slapes or whether only a footplate was avail- ment of an inferiorly based musculoperiosteai fiap able for reconstruction" In a review o{ 17 published (I dc this canai up or canal dorn,n, either to recon- studies (comprising almosi 1,500 palients) on pedi- stitute the lateral cortex or to use it lo cover an atric cholestealomas, the cumulative rate o{ recur* obliterative material). The flap is eievated and the rent ancl residual ciisease was 427u with an intact mastoidectomy is done. When ohliteration is done canal wall, and about halI that when the canal wal1 for the canal-down techniqle, I almost always use was removed. bone patd, u'hich is collecied from the iateral mas* Even though I prefer to perform an intact canal toid cortex at the beginning of the procedure usirrg wal1 proceclure, lhere are certai:r situations in a Sheehy collector" which a canal-wa1l-down procerlure may be pre- Over lhe years I have learned much from revision ferred, namely, a singie hearing ear when follclrv-r"rp surgery, and especially why the iirst operation is problemaiic, or if the patient is a poor anesthetic lends io fail. This is i:ne of our leasl successful pro- risk and only one sursrlry is desired. Intraopera- cedures*certainly much less successful than, for ex- tively, the findings of a small rnastoid or horizortal ample, stapes sur5 ery. lt is not always the choles- canal {istula or significant erosion of the canal wal1 teato;:na that is the problem, It may be mechanical may also leacl to a canal-wall-down approach. Sig- factors, something sirnpie, such as a high facial nificant erosion oI the posterior and superior canal ridge in canal-w,a11-down surgery, or a very poor wall can be repairerl with cartilage or bone. Repair meatoplasty preventing cleaning oI the mastoid wilh tragal cartilage is a very satisfactory way to bow1, follow,ed by residual nr recurlent granulation deal with this problem. tissue in prediciable areas*tegmental cells, sinal du- In conclusion, in this series of pediairic patients, ral cells, tip, the facial recess, and the hypotympa- the majority were rnanaged rtiih an intact canal num. In a cerlain sense, ii is harder to do a good rva1l procedure, and 84% of patients so treated canal-wali-down procedure because it is more im- achieved a disease-free stale during the follo:.v-up portant to eliminate as manv cells as pr:ssible to period while maintaining the canal wall intact. We prevent recurrent disease. The areas thai tead to recognize thai an intact wall apprr:ach will necessi- cause troutrle in the canal-wall-down techlique are tate more operations to completely eradicate the the residual tegmentai ce11s and sinodural ceils; an- cholesteatoma, br"rt it is my belief that the extra mor* other area that is particularly problematic is the so- bidity and cost, r,r,'hen averag;ed over many decades calleil hypotympanic or infralabvrinthine cell tract. of 1ife, is justifiable. I was trainecl to respect ihe middle eal: mucosa, Dr. Gantz: Nexl is Dr" Joe lladol, from Massa- and it was generally prohibited to do much in the chusetts Eye and Ear In{irmary, who has a com* \4ray o{ drilling in the middle ear. The {act remains, pletely different way o{ managing cholesteatorna. however, that in a numher of patients I have seen Dr. joe NadoL Thank you, Bruce. I'm pleased to with recurrent disease, the recurrence is exclusively be invited. Bruce asked me to give a short summary (or almost exclusively) i:r the hypoiympanic celis. of how ta decide bet*'een a canai-up and a canal- This can usually be determined with CT. lsolated down procedure. I think he was assuming lhat most hypotympanic cell or infralabyrinthine r:iisease oc- of the cases we do fire canal wali down, and in fact casionally can even erode into the men"rbranous that's true" Most of the procedures ] do are revision labyrinthine. How well do we do with these cases? surgeries, and that probably biases me. The reasons We conducted a study about 3 y€ars ago in which for choosing an open cavity or canal-wa1i-dr:wn we looked at 272 palierts, most of them with cho- technique are, obvii:usly, to revise a previous canal- lestealorna, some withoul, and folk:wed them for a rvail-down procedure, lo lreat recurrence rt ith loss minimum of 12 months (mean of 30 months) to see of integrily of the posterior canal wall (which Paul hor,, w'e did and what factors determined success. jusi mentioned), and for cxposulr. purposes, mainly Most of the procedr"ires were revision procedures, in the case of a large cholestealoma on a small mas- which is a characteristic of our practice, and the toid. If the dimension of the mastoid from the lai- majoritv were canal waii down becarse of that. We eral venous sinus to thc posterior wall is about the used a grading scale {or evaluations: 0 {or complete same as the dimension from lhe posterior r,r,a11 tn cure and 3 for total failure (continued dailv r:tor* the anlerior wa1l, I would consider that a small mas- rhea); grades 1 and 2 represented episodes ol olor- ioid. Finaliy, if the patient $eems to have chronic rhea o{ increasing duration that could be managed eustachian tube dysfunction in both ears, I tend to medically and did not require revision surgery" Of use the canal-wali-dow,n technique. the 272 patients, about 55% had a dry ear that 17 PAN[L DISCUSSICIN sitayed drlr through the period, and anolher group lilatr:d and inadequate operative exposlire. i preler had recurrences l-:ut did not requit:* revision :rtr- to do procedLlres as one operation, with reconstruc- gerv. ir-rterestingly, in those without cholesteatorna lion performed simr"tltaneously with ablatirn of the it was more di{Iicu}t to achierre a dry ear. This was disease, and if regrowth occurs, I consider tlre pro- statistically significnnt in tirc cholesteatoma pa- cedure to have failed. I don't go back for a second- tients, who did a little bit better than thosc r,r'ithout. look proccdure. lf the eardrr-rm is retlacted so that l The outcome was not influenced by primar;r ear have an epitvmpanic defect but a retracted pars revision surgery x,ith the carral up or down, bv the tensa, or if there is squamous epilhelium lining the extent of the choLesteatoma, or e\ren by the extent of mlddle ear space, 1wi11 take lhe canal wall dr:lvn. i the granulation tissuc. This remains one of our least don't think that these ears u,i1l be ventilated prop- successful procedures and leacls to manv revisiurs. erl\r, and I am concerned that there nrill be recut::ent Dr. Gantz: Thank you, Joe. Finallv, Simotl Pa- disease in ears x'ith patx ertstachian hibe function. risier, of l-enox Hi1i, Nen'York City, will address Hyperplastir polypoid middle rrar mucosa is .'r the group. very poor prognostic indicalor. ln ears with a verv Dr. Simon Parisier: Bruce askeel rne to t;r1k about thir:kened lamina propria abliterating the middie sui iable cases for canai -lr,all-up or canal -wa l l-d rirvn ear space, if I have to peel oi{ the rniddle r:ar mu- procedures. I individualize the decisilxr, and al- cosa, lhe likelihood of having normal mucosa grow- thougl"r some of the decision rnaking is dclne pre- ing back is prt"rblemaiic. If ihe mastoid is rea11y scle- operatively, basically it is an intraoperatil'e deci- rotic, snch thai the ear really has an ossified an- sion. ln frying to decide r,vhether I will leave the trnm, I would perform a canal-r,va1l-down canal r,r,all up, one of the factors 1 am concerned procedure. with is recurrent cholesteatoma, or cholesteatomas We looked at the treatment of congenital choles- that result from the formation of retraction pockeis, teatoma in children; the arreraEie w'as 4 years (range, either because of poor eustachian tube functietn or 1*12 years)" A canal-wa1l-don n procedure was per- because of other unknown factors. lt is r.ery diffi- forrned in 17"/u. Facial recess appxrach closed pro- cr:it for us to assess er-tstachian tubule funciion. We cedrrre rn 7'lr', the remairrder of these ears could be know how to work in the nasal pharynx, n'e know handled with a tyr"npanok:my. ln acquirerl pediatric how to work in the ear, but lvc reaily don't har''e cholesteatoma (216 ears), the cholesleatomas were anything that tests or acldresses the eustachian either acquired primarily or followirtg a previt-rus tr"rbe. Clinically, I look at these ears a:nci { look at the surge rv. A clnsecl canal-wall-up procedure was per- pars tensa, tu determine :,r.hether it is r"rormal, and formed in 52'X, and an open canal-wall-down pro- then 1 look at two other {actors*lhe middle ear nli.'r- cedure was performed in 48./n. cosa and the size of the mastoid. i will illustraie i bt:lieve that the cholesteateima sl"roul-l be re- with the case of a person r,vho has a pars flaccid, or moved completely at the initial operation, even if it retraction with an attic antral block. (The illustra- invoh,es the stapes footplate or facial nerve. With tion is from Rrackmann's Atlas, so i'd like to thank regard to recidivisnt, insofar as the folbw-up r:f hinr.) The middle ear is cloar. lJut there is aeration these youn;; patients isn't perfect, we harre adopted of il-re middle ear and dist:ase in the epitympanum/ tlie Kaplan-Meyer siatistical analysis for survival and that fact woLrld lead me to h'ant to preserve the that il populal with hratl-and-neck cancer sur* ranal w'all, reconstructing the damaged part. lf I geon$" In a study of cholesteatoma follcw-up in enter an ear and it has a mncosa that resernbles aciults, recidir.ism follor,r,ing all procerlures pla- what i encounter doing a micldle car exploratiorr {or teaued at alrout 10 years, because of the recurrenl otosclerosis, lhat is a very favorable sign that the cholesteatomas. Itesidr,rals only occurred out to 3 custachian tube veniilatiorr is uormal. I{ tlrerc is yelars. Tn pediatric cholesteatoma there is a similar middle ear e ffusiou and the eustachian tube is not curve that plateaus at 10 years, but it is a little bit r,vorking functior"rally, in some of these ears I will higher. When adult cholesteatoma elata are ana- prit a ventilating lube. lvzed by caual-wall-up as opposed to catral-wal1- I lcok at the size of the mastoid. Tl-ris is a small down procedures, regrou,th occurred earlier, and rpitympanic cholesteatoma in an otherwise pneu- surprisingly, there wasn't that much difference. The matized mastoid. The cholesteatnma is abutting the pediatric cholesleatom;r data show that lhe canal- lateral semicircular: canals, so it is doing some datl- wal1-down approach results in a I5% reg;rovr,lh ralt: .{ age, br-rt this ear rvould lend itself well to a canal that plateaus at about years, br-rt the reci-irrent rva11 procedure. cholesteatomas continue up to ahout 407r,, and they Thc indjcations for performing a cixral-tva11- can occur as late as 10 year:s pilstoperatively. dor,r,n procetlure inclucle ears lhat are poor:ly rren- Dr. Gantz: I harre had difficulty for 17 years in 18 trying to dercide L:etween canal wall up and canal with bone chips up to the attic so that the bone pat6 wall down. Like Sirnon, l show,ed a lot of n-iy canal- does not go into the rniddle ear space. Then you fill wa1l-up decisions, the canal walls came down, and ihe mastoid with bone pat6, you put the posterior I was frustrated. Even after putting large pieces of canal wall back, and you use a cotlel specuium to cartilage in the posterior-srrperior quadrant, I see all the way dow'n to the tympanic membrane. would find that the eustachian tube didn't frrnction, }{u gauze and bacilracin are placed in the ea: car:ral and eventually the retraction would go underneath and left {or 1 week. I have drained the mastoid with lhe cariilage and would start lo accumulate debris, a Penrose drain for 48 hours and we have :un lhe and we would have to take the canal wall down. br.lne pat6 through aqueous bacitracin to try and We had to do thal in more than 50n1, of children we reduce the chance of postoperative infection. This is treated at Iowa" At the 1976 Cholesteaioma Confer- an x-ray of one of my patients who cr':mplained of ence I heard a presentation by a Slyedish group that some ear pain, but you can see that this bone fills in, describetl 122 cases r,r.,ith a S-yeat follow-up and no the posterior canal u'all is in good shape, and in this recurlent cholesteatomas. l{esidual disease ai S situation you have the bone all the way up to the years was zt:ro, there were only ihree perforations, cortex. there were no retraction pockets, and ears were dry These results were tabulated by I?au1 Canti, our in 100'/n" The 10-year results from this group were f"ellow, and one of our residents, Marlin Hansen" similar. I tried to cio the procedure. The highliglrts We have treated 50 ears this way since ]anuary of it are a complete mastoidectomy, rvith a 1ot of the 1997. Ow follow-up is only 26 monlhs, so orr re* steps thal others clid before the Swedish Sroup, sults are very earlv and preliminary. One of ihe such as use of an exiended facial recess and collect- problems was that 13% had postoperative infection ing the patd with thr: Sheehv bone pat6 collector. for which they had to be rehospitalized and given The skin of lhe posterior carral wail is elevaterl for- IV antibiotics. Al1 of the infections cleared with an- u,ard. |'Jo .incisions are made in the posterior canal iibiotics. We had no loss o{ posterior canal yra11. ln wa1i. l{enrove the posterior canal wall (as the Wul one patient a partial resorpiion occurred, but the steins used to do with the microsaw), get ai1 of the posterior canal wa11 is intaci. Of the 60 ears, we cholesteatr:ma out, and yor: have a canal wal1 down have looked al 47 so far. Two had a pea:1 in the ovai at that time. Then you put a Silastic spacer in and r,r.irrdow that we remorred" The posterior canal wall come back in a second stage for rect.;nstruction, dur- retractions ;rnd the posterior-sr-rperior quadrant are ing which you repiace the posterir:r canal wa1i. You zero. We lrad twa that had perfotations after the block the attic with bone chips that you take with a first procedure. We repaired them, and they are chisel, and then you fill the nrasioid with bcxre pat6. no*,'healed" Al1 of lhese ears are dry, meaning they 'Ihe objective is io get ricl of all of the mucosa in the don't have to be maintained and the paiients dcln't mastoid, which is vcry problematic becausc it re- have to make clinic fo11ovr.-up visits. We will con- sorbs nitrogen. What I demonstrate here is after: tinue to follow these patients. you/ve done a complete mastoidectomy, using a How did we do with hearing? We are not doing nasal clrisel as yon would a plane to take some very as well with hearing. We looked at our patients thin bone chips. The canal skin is taken ancl lilted preoperatively, 0*10 IJb, air-bone gap, 11*20 Db, forward before you cnt out the canal wall. Then, 21*30 )b, and greater ihan 30 Db. Posioperativeiy with a reciprocatirg saw*this is a Stor:z microsaw, we are reducing ihese figures, but we are stiil hav- but you can use a handpiece on a Fisch drili and dcl irrg significant air-bone gaps" The air-bone g.rps in lhe same thing*you cut out the canal waii so ihat it these 37 patients are evident from these audio- is at an ang1e, so that when you place it back it will grams, which a:e lhe most recent audiograms ob- not fall back irr the mastoid. Now you have a canal- tained, some only 3 montl'rs postoperatively and wall-down situation, as you have laken out the others a year postoperatively. These resuils are not piece of bone, and you can do a very thorough joir as good as have been reported. We are not putting of removing the cholcsteatoma. You take a large tubes in these ears, we are not trying tr: re-aerate piece of {ascia. You put a Silastic spacer in the them. This is just the disease process of the eusta- mjddle ear. If you don't h;rve a stapes, you put chian tube dysfunction again, and it's probably the another piece in there in the oval rvindow,, and yor-t reason. The advantages here for rne are improved put ihe Silastic spacer on top of that and then ase a access and renoval nf all the disease. I think we lry big piece of fascia to go all the way undenrcath tire to remove all of the mucosa and gei rii.1 of it so that tympanic membrane and up the canal wall where we don't have the ncgative resorption of nitrogen. you've made your cr-rts. J'his fascia goes outside of Long-term debridement is not necessary. It's a one- where you've made the canai wall cuts. You line lype procedure for aii comers, and I don't have lo 1S PANEL DISCUSSION make a decision. This is a big problem for me right cartilage in every case jn the posterior-superior now, because it is still a tw'o-stage procedure. So quadrant of the whole tympanum? Pau.l? that is another alternative. I will continuc to fol1ow Dr. Lambert: I dern't. At the first stage, things I do lhese patienls. We do not yet have long-term re- to try to prer.ent a retractiein-and again, most of my sults, bul when I was doing canal wa11 ups and cases al'e staged*include placing cartilagt in the de- following the patients, I was taking down a lot {ect of the canal if some elosion of the medial aspect more at ihis time period. of the canal has occurred, stabilizlng that cartilage Now, some questions for our panelists. Simon by removing lhe perichonclrium on one side, and discussed his preoperaiive parameters {or deter- then draping lhat onto the canal wall" Staging is rnining which procedure to use" Jot, l,r,hat procrl- helpful i.n lerms of placing a large Silastic sheet into dure do you perform if ;rou have a virgin ear lhat the middle ear. That extends back into the epitym- has not been operated on before? panlrm, back into the mastoid, ancl N,i1l freqrrently Dr. Nadol: i would predict a canal-wall-up pro- abut the medial aspect of the superior and poste- cedure-and almost always do it*when 1 encounler rior-superior canal wa1l and help prevent relrac- an entity that I call chri:nic inactive otitis media tions there. if at thE second stage I see changes in with frequent reactivation. That is an ear without the lriddle ear that are a 1itt1e disconcerting, if the cholesteatoma" It is ;n ear with a perforation that mucosa is ver:y, thick, and certainly if there is fluid drains intermittently; in most cases lhere is an atiic in the middle ear, if any initial retraclion is evident, block. For me, that is the perfect case for a canal- then at that point I u'ould reconstruct a large part of wall-up procedure, which can almost always can be the tympanic membrane r,vith cartilage. d$ne. ln general, on the first time through, I ap- Dr. Gantz: Simon, do you use cartilage primarily proach these cases as a canal wall up. The circum- to try to prt:vent that re-retraclii'rn? slances that will make me go to canal wall down we Dr. Pariser: Yes" have already talked about. Dr. Gantz: Does it work? As to the mastoid cavity, I do not believe there js Dr. Pariser: Not alwavs, no. Sometimes it retracts anv intrinsic vaiue to preserving it, so I have noth- arouncl ihe cartilage, and that's a problem. lnserting ing against obliterating it completely. ln fact, mas- middle ear ventilating iubes has not been univcr- toid cavily obliteratiern is part of (almost) elrery ca- sal1y successful either. nalwall-down procedure that I do' i do not do an Dr" Gantz: Paul, are lou in the same siiuation? obliteration if thr: cholesteaioma is adhereni to the That is, dn 1,ou put tubes in lhese kids when you dura in the posterior {ossa. I simply can't get it off slart to see fluid re*accumulating? that dura reliably, and therefor:e I don't try" Dr. Lambert: Yes" { don'l do that at lhe first stage, Dr. Gantz: Pau1, what parameters do you use but at the second stage if I see {1uid, certainly at that when you are making this decision? Can you make point, and then subsequently durlng {ollow-up. it preoperative? Dr" Gantz: In other wolds, follon -up of these Dr, Lambert: Agai:r, my preference is to have an young patierrts has to coniinue for a Jong time? intact canal wall, so I look for: reasons to do a canal- Both yarr and Simon see yorrr canal-wa11-up pa- wall-down procedure. If there is a large degree of tients on a yearly basis? joe, with your mastoic"l cav- erosion of the posterior canal wall, that might sr,r'ay itv obliteration technique, do you do skin grafting? me, but not always. If 1 sec a very retracted tym- If so, do you har.e to see patients year:ly to clean lhe panic membrane, not just in lhe posterior-superior gralts and keep lhem free of disease? quadrant bui the entire pars tensa, that is some- Dr. Nadol: Every mastoid i do geis skin grafied. times a red flag. trf the patient has any vertip;n or I take skin at the beginning of the prncedr"rre before sensorineural hearing 1oss, anr-1 particularly a sen- the ear is even draped out. But most of that skin is sorineural hearing loss associated w'iih a possible applied to the anterior canal wal1, and the principal Iistula into the horizontal canal or even intsl the reasor for skin grafting is to maintain the anterior cochlea iiself, that r,r,'ouid certainly sway me toward angle between the anterior canal wall and the tym- a canal wall down preoperatively. With regard to panic membrane. Skh grafting over fascia, at least the intraoperative sitriation, I ag;ree r,r,hat has been in my hands, doesn't l,vork ver), we1l, at least ini- said here, l:ut I reiterate that I approach just about tiall1,. 1 do nol attempt to do a skin graft in the bowl every case with the intention of maintaining the area or over the musculoperiosteal flap co:,ering canal wal1. bone pat6. A minority of patients will lleetl a de- Dr. Gantz: 1gs1ar, for the people t ho are doing layed spllt-lhickness skin grafi in the rffirc. ] will their canal wall ups, Simon anel Paul: When you do do ihat gralt about 6 weeks postoperatlvely if lhey this canal wall up, do you place a large piece oI are not epithelizing adequately. The procedure is 20 done under local anesthesia and takes about 20 ageable). I routinely graft the mastoid cavity with a minules. piece oi connective tissue, the iateral surface of the As far as follow-r-rp is concerned, canal up or ca- temporalis fascia. So, in most ears, most of the bone nal down gets followed, aithough it's not a question is grafted primarily. I do not depend nn secondary of th* cleaning lequirements: they all trrarre to be granulation tissue. follow'ed" Follow-up a\,.erages about twice a year, Dr" Gantz: I'd like to open this discussion to the but some patients need to be seen three or four floor. You have heard from the experts. A11 of us times a year. I wish l knew why that is the case, lrut have some problems, and we haven't {ound ai1 of that is tire case" patients And some return after 5 the answers. Are there questions for these experts? years with no follow-up in the inlerim, and there's Dr. Kevin McKennan (Sacramentei): I have a not verv :nuch in them, even though it was a canal- question for Dr. llJadoi. In my expe:ience will:r re- wall-down technique. jf I also let patients swim vision $urgery on patients using the canal-wa1l- they }rave never had any skin breakdown and have down technique, in the vast majority of cases, if 1 a dry, clean howl. I don't prevent them fronr swim- took off the mastoid tip and enlarged the meatus, I ming or using hearing aids. Generally ihat is not an found 1 did not lrave to do early skin grafting. I had issue, as long as they have a stable, dry, epiihelia! sparingly done skin gr:afting ized bowl. in mastoid cavities, but usually in patienis who had undergone mul- I)r. Gantzl Simon, do you follow patients and tiple operaiioll$ or who were e1derly. In the patients clean the bowls on a yearly basis, or do you do whom l have seen with poor epilhelialization r:f the something to make them self-cleaning? mastoid at 2 or 3 months who underwent regular I)r. Pariser No, 1 don't skirr graft them. I pre- cleaning $f ihat ear over a period of 6 or 12 months, srrve the anteriot canal r,lral1 skin universally on the epithelium q'ould sometimes keratinize and lhcse ears and x,iden the canal. I think the meato- look great at a year urhen it might not have looked piasty plays a critical role in how often they have to very good at 3 and 6 months. So, my qr-restion is, be cleaned. 1{ you have a small openin[, that is r.n",hat is your rationale for going to be a problern" But it's unpredictable. I've doing eariy skin grafting in a mastoid cavitir approacheei never been abie lo figure out why $ome €ars are by a canal-wall- self-cleaning after a canal-wali-dor.vn procedure down technique? Dr. Nadol: I perforn'r skin grafting on and othr"'rs arcn't. [ .tgret, vtith Joc. all of my patients Dr. Gantz: Joe said that he wasfl.'t concerned during the pr:ocedure. I eievate lhe anterior about closing off or obiiteraling the mastoid, which canal skin in all cases so that lt is basicaliy the mir- he rloes in almost a]1 of his cases. Paul, does that ror image of a Kerner fiap*that is, the skin is e1- concern you? Is the technique I have described svated based on the cartiiagini:us auricle. I pul that something you ihink will be a prol:1em l0-1S vea:s back in, but it never quite goes all the way back from now? down. 5o, 1 might not do it in a case where a gor:d Dr. Lambert: You have to consider where the re- part of the tympanic membrane, which has epithe- current disease or, better said, the residual disease lialized, is pr*served, bui I wor.lld almost always dc: actuaily occurs jn these ears" Jt is usually in the it in total drum replacement cases. So, the early skin micldle ear space or epitympanum, .tncl typically grafting ls nr:t so much to achieve epithelialization nnt l:ack in the mastoid. I routinely place bone pat6 but to make more preclictable lhe achievement af a or some fascial graft over the mastoid area to sulcus anlerir:r1y between the tympanic membrane smooth the contour, so I am not too concerned as graft and the anterior canal wall. That is something long as i feel comfortable that tr'vc removecl the I slrongly feel influences the hearing oulcome. De* cholesteatoma. Having staged these ears, I get a Iayed grafting is not always per{ormed after granu- chance to look again about a year later, and i{ there lation has occurred. Most of them, as you say, will is no disease there, I feel very comfortable, epithelialize on their on,n, and during that period Dr. Gantz: Simon, what is your feeling about the bo:v1 is actually getting smaller. 5o there is a oblilerating ihe mastoid cayitl,? certain advantage ln not rushing it" I te}l patients Dr. Parisen In a large pneumatizecl mastoid, I that this is a bit like guin surgery. It's going to take amputate the tip completely and sew clr:wn lhe a long while before this ear is heaied, measuted in periosteal fiap to the digastric niuscle, which effec- weeks or sometimes months, and they should not tively makes lhe large mastoiri recess smaller (it be disappoinled with the fact that postoperative doesn't eliminate it completely, but it makes it man- care cor:tinues for several weeks. 21 TRANSACTIONS 2OOO / AMER:CAN OTOLOCICAL SOCIITY ANTIRIOR SLJ BAN N U LAR T-TU BT FOR PROLONCID MIDDLT EAR VTNTILATIO\I DURINC TYMPANOPLASTY: LONC-TTRM FOLLOW-UP Rauinilhrs C" Elluru, M,D., Pll"D., Reevs D'hnnda, I\,(.,D., lad A" Coebcl, M.D., F.A"C.S', nnd l. Gail NcelY, M'D., f.A"C.5. ABSTRACT Objective: We have previclusly described the use of anterior subannular T-tubes (n = 20) for lorrg-term nriddle ear ventilation. ln lhe present sludy we exanrine a larger palient populatir:n (n * 38) and a longer follow-up interval (average > 2 years) to evaluate the efficacy arrd safety of anlerior subanr:ular tympanr:stomy. Study Design: Retrospective nonrandonrized case review. Setting: Terliary referral hospital. Patients: Our series consisted of 38 consecutivs patierrts with a riiagnosis of eustaclrian tLrbe ([T) dysfunctinn, adhesive otitis, nredia andlor r:hronic oiitis media witlr a perforatiorr who under\&/ent a tympanr:plasty. lntervention: A subannular T-tube was placed antericrly at the linre of tym- panoplasiy 1o provide lang-term middle oar ventilation' Main Outcome Measures: The main outcomes of this sturiy were tube p6sition, tube paterrcy, and nrirJdle ear vcntilation. ln additicn, hearing was evaluated both pre- and postoperatively, and any complicaticlns were noted. Results: Thity-nine ears in 3B patiernts (24 females,.l4 nrales) received an anlerior subannular T-tube at the tinre of tyrnpanoplasty" Median patient age was 36 years (range, 10*75)" All 3S patients had ET dysfurrction" ln addi- tior:, 22 had arjhesive otitis media, 23 had chronic ctilis media, I3 had a cholesleatoma, 'll had tyrrrpanic membrane perforations, and 3 had a cleft palate. AII patients underwent tympanoplasty; one patienl receivecl a subannular tube in the contrala{eral ear withnut tynrpanoplasly. Iighteen patier:ts underwenl a concornilant ossiculoplasty and 7 underwsnt mastoidec- tomy. Follow-up ranged from l to 48 months (average, 25 months)" Tlrree tr"rbes had extruded within 2 years, irr r.rne-. case resulting in a persistenl pedoration. Post- operative complications included one case of a partially extruded prcstlresis, two cases of tipped prosthesis and persistent iympanic membrane retraction, and case a{ a plugged tr:he. All other tubes were patsnt and shr:wed no evi- dence of rnigratiorr. Furlhermore, tlrere wers no cases o{ anterir:r canal blunting or ingrowth of epithellunr arr:uncJ the tube' Conclusions: Anterior su[:annular tympanoslonry is a safe and effective 22 TRANSACTIONS 2OOO / AMERICAN OTOLOCICAL SOCIETY method for long-term middle ear ventilation in patients with chronic tT dys- functicn. Reprint requests: ]oelA. Gnebel, M.D., F.A.c.S., Department of otolaryngology, wash- University TStoa School o{ Medicir:re, 660 SouthEuciid Avenue, Cu**p.ru'6ox 8115, st" Louis, Mo 63110; ph. zt4-747-a5*; fax 314-362-zr2z. E-mailr joel @vertige "wusti.edu .)1 TXANSACT:ONS ?OOO I AMTRICAN OTOLOCICAL SOCIETY DILAYTD FACIAL PALSY AFTER STAPTDECTOMY Xiwtxi Ge, M.D., aud ]alw {. She*, {r., M"D. ABSTRACT Obieetive: To study the incidence, pathogenesis, and prevention af delayed facial palsy aiter stapedeclomy. Study Design: Retrc;spective case review. Setting: Otology/neurotology refetral center. Patients: A series a{ 2,152 stapedectomy ptocedures pe rfnrmed in the past 12 years. lnterventian: Delayed {acial palsy after stapedectonly was studied. Main Outcome Measure: House-Brackmann facial nerve grading system and serum antibody titer tests fcr herpes simplex virus lypes I and ll and varicella zoster virus. Results: Delayecl facial palsy occurred in 1 1 of 2,152 procedures. Delayed iacial palsy occurred from 5 to 16 clays (mean, B days) after stapedect6my. Predisposing {aclors were bony facial canal dehiscence, wilh bare facial nerve herniation in 5 patients, cht:rda lynrpani nerve stretchecl, manipulated, or cut in 2 palients, granulomatous reaclion to Cel{oam in I patient, fever blisters on the Lrpper lip in 1 patient, and viral sinusitis in 2 patierrts. Elevated antivaricella titers were iound in all 6 patients studied. Anri-HSV type land ll "riibo,lyantibody tilers were elevated in 5 of 6 patients. Acyclovir was ef{ective in preventins delayed facial palsy in one revision stapedectotny patient, who had delayed facial palsy after prior stapedectonry in the same ear with an elevated anti-HSV antibody titer" Conclusion: Delayed facial palsy occurrecl in 0.51% after stapedectomy. Serologic investigation suggests activation of latent herpesvirus" Mechanical irritalion r:f the facial or chclrda nerve during operation may trigger the activa- tion. The anti-herpes virus agent acyclavir may prevent delayed facial palsy a{ter stapedectomy in patients suspected of this complication. Reprint requests: Xianxi Ce, M"D., 6133 Poplar Pike, Mer:rphis, ThJ 38119; ph" 901-761- i72A; fax 901-683-8440. H-mail: sheacl@aol'com ?4 TRANSACTTONS 2000 / AMTR|CAN OTOLOCTCAL SOCIITY INCIDTNCE OF TACIAL NTRVT DIHISCINCT AT SURCIRY FOR CHOLTSTEATOMA Samtsd H. Selesnick,l,vl.D., F.A.C.S., nnd Alnstair G" Lynn-Macrae, M.S, AB$TRACT Objective: Iacial paraiysis can occlrr after surgery for cholesteatoma. The risk af facial nerve iniury is great when the nerve is not covered by its normal bony fallopian canal. The objective of this study was to identify the inciclence oi far:ial nerve dehiscence in patients r-rndergoing surgery for cholesteatcma. Study Design: Retrospective chart review. $etting: Tertiary re{erral hospitai. Patient Population: An assessment r:f all cases pe{ormed hy the senior author fron: I991 1o i 999 identified 59 patients in whom adequate clata were available for analysis. These patients ranged in age from 3 to g2 years" sixty-seven op- erations were performed in total. Intervention: Surgery for cholesteatoma, including tympanoplasty and mas- tnidecton-ry. outcorne kleasures: The presence of facial nerve bony dehiscence aftel exenteration of disease, and postoperative iacial nerve function, Results: Facial nerve bony dehiscence occurred in 33u/, of the total opera- iions analyzed, including 30% r:f the initial surgeries and 35% of the revision surgeries. The dehiscence was present in the tympanic portion of the facial nerve in the vast rxajority of patients. Of the gz,/o at patients with normal preoperative iacial nerve function, all retained normal function postoperatively. Conclusions: Facial nerve dehiscence in our seriEs was far greater than that reported in the literature, underscoring the fact that this is an unclerappreciatec{ finding. Tl"rese findings merit increased vigilance when surgeons dissect near the faci.ri ncrvL,. lntraoperative facial nerve fionitoring has proved to be of value in facial nerve prsservation during acoustic neuroma resections, and mav have a role during sursery for chalesteatoma" Reptilf requests: Samuel H. Selesnick, M.D., Department r:f Olorhinolaryngology, weiil Medical col}ege,520 r. 70th Street, New york, Ny 10021; pir..z12-ya6-zixz;lix 212-7 46-2253. E-rnail: [email protected] DISCUSSION DISCUSSION PTRIOD III: Papers B*1 0 Dr" C. Gary ]ackson {l{ashville, TIrJ): This series suifate by nrouth and to clean the ear canal and of papers is now open for discussion. mastoid bowl and paint it with gentian violet once Dr. Gerry Gianoli (New Orieans, LA): .l have a a r,r,erk, I harre not seen a failure with ihis routine. couple of questions {or Dr^ Ce' How long after I think il r,vorks very we1l. surgery did vou obtain the iiters in vour paiients? Dr" Xianxi Ge {Mcmphis, TN): The antibody titer You mentioned they were elevated" Were you re- tested was IGC. ferring to ICM or iGC titers? Finally, dici you mea- Dr. Douglas Green (iacksonville, FL): 1 harre a sure titers in patierrts u,ho did nr:t derrelop facial question fcr Dr. Selesnick or his assistant: Did you palsy? use intraoperative facial monilr:rring with the high Dr. Richard Ruggles (Cleveiand, OH): A quick incidence of dehiscence of the facial nen,e and the comment regarding the persistent problem follow- good postoperative trerve results? I am curious as trt ing mastoid surgery, which.l didn't get to last time. wheiher it was used, and helPful. Granulation tissue is usually the cause of this prob- I)r. Samuel Selesnick {I{ew York,lVY); Yes, we lem. if one takes the time to put the patient on zinc routinely used nerve monitoring in that situation" 10 TRANSACTIONS 2000 / AMERTCAN OTOLOCTCAT SOCrrry A COMPARISON OT HEARINC RTSULTS IN I NTRATYMPAN IC CINTAMICI N THERAPY Michelle L" Facer, D"O., Calin L. W. Driscoll, M.D", Stephen G. Harner, M.D., Ceorge W. Facer,lv'|.D., Clmrles W. Beatty, M.f)., and Tkomas l. McDanald, M.D. ABSTRACT Ohjective: lntratympanir: gentarnicin is a well-establisherl and efiective treat- ment for intractable vertigo of a peripheral vestibular etiology. Sensorineural hearirrg krss is a potential complicatinn of the treatment and is directly related to the dose delivered. The risk of hearing k:ss with various treatment regimens has not been clearly delineated. The objective of this study was to establish the risi< of hearing loss and to clarify the relatiorrship between hearing loss and rJrug dose. Data sources: A MIDLINE search of the [nglish literature up to June 1gg9 was conducted using the search ierms inlratympanic, gentantir:iin, vertigo, and Mdni&re's disease. The bibliographies ol each article were reviewed to identify other relevant publ ications. Study Selection: All studies reporting pre- and posttreatment hearing resulls and treatment dose were inclr-rded. The analysis also included the prospectivety collected data from approximately 100 patients treated at ihe authors' institu- tion. Data Synthesis: Pre- and pnsttreatment hearing results were comparecj, and the relatinnship with ireatment dose was explored. Conclusions: lntratympanic gentamicin c;ln be delivered with limited risk to hearing in patients with vertigo oi peripheral labyrinthine origin. ln parienrs with useful hearing, the goal of treatment should be to deliver rl':e lowesr dose of gentamicin that relieves the synrptoms. Some current protccols may use a dose higher thar: necessary for vertigo control and increase the risl< r:f hearing loss. R.eprint requests: Michelle L. Facer, D.o., Departrnent of Otolaryngology, Mayo Clinic, 200 First strert s.w., Rochester, MN 55902; ph.502-284-2511; fax 507-z*44gaz. E-mail: [email protected] 27 TRANSACTIONS 2OIX} / AMTRICAN OTOLOCICAT SOCITTY TMPACT OF MENITRE',S DrSrASr ON QUALITY Or Llrr lohn P. Andus*n, PllD., and f effrcy P. Harris, M'D., Pk.D. ABSTRACT Objective: To describe the health-related quality-of-ii{e situation o{ patients with M6nibre's disease in whnnr convenlional tlrerapy has failed and who ;rre candidates for {urther medical intervention. Study Design: Pretreatme nt inlerviews to estalilish baseline characteristics in terms of quality-of-life measures before further medical intervention. Setting: Tertiary referral center. Patients: Nineteen adult patients with Mdni0re's disease i12 *,omen and seven men) in whom conventional therapy had failed. Ages ranged fronr 32 to B 3 years. lnterventions: None as yet. Pretreatment baselinE interviews have heen con- ducted. Main Outcome Measures: Quality of Well-being (QWB) Scaie, 5F-12 Physi- cal and SF-i 2 Mental scores, Cenler for Epidenriologic Studies C Depression Scale. Results: The QWl3 score for patients with Mdnibre's disease r:f .561 indicated that tlrey were losing 43"9"/o of wellbeing compared with patients with no symptoms and full funclional status. On days patients had symptoms identified as characteristic of acute M6nibre's disease episodes, QwB scores were lower than on days patients did not report such synrptoms {P = 0.000). Patients' scores of 38.9 on llre SF-12 Plrysical scale were l:elow ihe general mean of 50 by more than 1 5D, and scores o{ 44.2on the Sf-l2 Mental scale were helow the general mean of 50 hy 0.5 SD. The CES-D score was 23.3 (a score of 16 or above indicates clinically significarrt depression). Conclusions: These findings indicate lhat {"1) the pretreatment conditir:n of patients with M6nibre's disease Can be measured by these instruments; (21 ihe instruments appear to be in substantial agreement al:aut a serious impairment of patients'quality oi life; and (3) days with acute episodes of Mdnibre's disease are significantly worse tharr days withaut sr-rch episodes. Treating physicians indicated surprise at the breadth and degree af debilitation experienced by patients with M6ni&re's disease (lRE #980609)" ph.D', Reprint requests: John P. Anderson, UCSD Medical Center,200 W. Arbor Drive $gsS, S*r-t Diego, CA 92103; ph. 619-534-2896; {ax 619-5311-464.2" E-Maii [email protected] 28 TRANSACTIONS 2OOO / AMERICAN OTOLOCICAI SOCIITY THT WANINC ROLE OT VTSTIBULAR NERVE STCTION AND LABYRINTHICTOMY FOR INTRACTABLE MEN IERE'S DISTASE Atris A. Akn'tadi,8.s., Patrickl. Antonelli, M.D., nnd GeargeT, singleton, M,D. ABSTRACT Objective: To assess the impaci of intratympanic gentamicin (ll-C) therapy on the need for invasive surgery (labyrintheciomy and vestibular nerve section) for i ntractable Mdnibre's d isease. Study Design: R.etrospective case review. Setting: Tertiary referral center. Patients: All patients receiving surgical treatment for Mdnibre's disease not controlled by medical therapy, for the 5 years preceding our aderption oi ITC t1987*1991) and the most recent 5-year period (j994*199S). Main Outcome Measures: Type, efficacy, and complications of surgical therapy. -l987 .1998, Results: from thx:ugh 61 patients with intractable Mdnibre's disease underwent labyrinthectomy (.lB patienrs), vesiibular nerve section (2), ITC (29), or endolymphatic sac surgery (12). Although the volume oi surgical cases doubled irom the first 5 years (16) to tlie last 5 years (30), the need for labyrinthectonry drapped from 87.5t'/,. nf cases before ITC to 10% aiter lTC. After the introductir:n of lTC, the use of ITC rose to 67aL, af cases" Of the three patients treated with labyrintlrectomy in the past 5 years, two did not have adequate sLrpport to perform ITC at home or to return for outpatient therapy, and *ne patient wa$ not offered ITC. Vestibular nerve section has not been needed in the past 5 years. Only one patient with bilateral disease reported no imJ:rovement with ITC. Complete or substantial control of vertigo was similar with ITC and invasive ablative techniques (90% vs. 95%). Conclusion; ITC therapy markeclly reduced the need for more invasive ah- lative surgery for intractable M6nibre's disease. Reprint requests: Patrick ]. Antonelli, M,D., Department of Otolaryngology, University of Fiorida, Box 1U0264, Gainesville, FL 326\A-4264; ph. 352-392-4461; fax 352-392- 6781. E-mail: [email protected] 29 D]SCUSSION IIISCUSSION PIRIOD IV: MENI[Rf'S ]lS[A5[ Papers 11-1 3 I)r. C. Cary ]ackson (Nashvi1le. TIIJ): These pa- tions. The only signiiicant changes were seen at lhe pers are now open for discussion" Dr. l",eutje? high frequencies of 5 and I kHz with 40 mglml Dr. Charles Luelje (Kansas City, MO): In light of and at 8 kHz with 20 mg/ml. lhe excellent paper h1, Dr" Harris and the plight of Dr. Antr:nelli: A numtrer of patients come back palients with M6nidre's disease, I'ci like to ask Dr' after a year or so and say thcy are starting tr: get Antonelli and lJr. Facer whether they r,r'ottld use woozy spel1s and fetl as thor-rgh ihe condirinn is intratympanic gentamicin in the onlv hearing ear of beginrring to come ba:k vory slightly. We do a tune- a person with M€niire's clisease. up in the office and give a little injection, and thev Dr. Patrick Antonelli (Caincsvi11e, FI-): Nothing do very rvell. like starting with an easy question! If a patieni's lifi: Dr" Richard Friedman (Los Angeles, CA): This rvas basically r:n hold because of set ere, intractable quesiion is fol Dr. Antonelli. I didn't g;el the dura- vertigo, I would ceriainly consider the use of gerr- tion of foilow-up in your study. in my experience tamicin o\rer some other modalities. Obviously the vast majority of these patients, symptoms recur labyrinthectomy is nol a major c*nsider:ation, br.rt withir"r months to a year. Again, I haven't been prac- with the success of cochlear implantation, we can ticing as long as somr: in thc ar-ir{ience, bui virtually be a bit more aggressive lhan we were 1L)*15 years all of the have gone to the nerve section, so I per- ago. As for performing neurectomy in an elderly sonaliy have not seen the pi:sitive results that you patient, that's a judgment ca1l. I don't think there is are reporting. any ans\,ver. Dr. Richard Kuggles (Cleveland, OH): i u$ed to Dr. Michetle Facer (Rochester, MN): At our iir- clo sac sllrgery too, and some of the other proce- stitution we have not trsed gentamicin in that situ- dr.rres. For the past i0 years I have been using ation; however, because of the low risk to hearing allergy management with skin encl-pr:int testing (and here I concur with Dr. Antonelli), it would be and provocative food testing. We have seen no a reasonable alternative to consider instead of sur- failures with ihis method. The disease is con- gical interrrentiur. trolled very r,r,ell, arrd palients are much more 3r. Michael Seidman (Detroit, MI): A {er,r,'qr-rick comfortable, as invasive procedutes are not being questions {or }r. Facer. You mextionecl that 2-3 dB clone. was siatistically significant in your patients. We Dr. Newton Coker (Houston TX): t have a ques- usually use al least 5 dB and call it inlerlest vari- tion for Dr. Harris. A nunrber of years ag*, when ability" I'm curious as to how' vou get statistical we studied patients with Mdnilre's disease, we ad- slgnificance out of lhose numbers, or perhaps I mis- ministered a battery of psychological tests, becau- unr-lerstoocl what you were tloing. se-as most herr r,r.ou1d colcur*these paiienls have Do you have any data on streptomycin? Dr. Shea a clifferent personality from most patients wc sec in uses streptomycin and frequently reports that its the o{fice. The psychological testing indicaleci a use is associated with a lower risk of hearing loss, high profile of depression in lhis group of patients. and-no offense*fhe statement of rrirtuall), no hear- These patients had active M6nii:e's disease, and by ing loss was rather bold, and malz $g dangerous to that I mean they were eitirer: suffering frr:m chronic make. disequiliLrrium or had recurrent atiacks of vertigo A quick queslion for I)r. Antonelli: Yirrcente that were poorly mar:raged by medical therapy" l3rrt Honrubia has indicaied that pericells r€$enerate urhat was not clear from our study lrras the actual even in the ma11eus, and so symptoms might recur problem: r,t'as depressi*n aggravating the vestibu- in 2-3 years. Could you comment? lar pr:oblems or were ihe vestibr:lar problems lead- Dr. Facer: Th 30 DISCUSSION Dr. ]effrey Harris (San Diego, CA): No, I can't* acceptar-ice of aminoglycoside trealment for M6- but that is a great quesliol. I expect most cliniclans nilre's disease" 1 stil1 prefer streptomycin, but that's today would say that patients w'ho are severely lim- why tl'rey make chocolate and vaailla, ;,ou knor,r,* ited develop neuroses as a consequcnce of the im- it's a difference of opiniorr. We have conre a loag pairment, because they begin lo wonder what way, in this Socieiy, to be talking ai:out the advan- might trigger the medical conditir-rn. So they start to tages of aminoglycosides and thc disadvantages o{ avoid things, and start to change their 1ife. labyrinthectomy and vestibular nerve sections. {'m not surc how you could answer the question" I)r. Kevin MeKennan (Sacramento, CA): I have You w,ould need to obterin a psychological profile used botlr gentamicin and vestibul;u nerrrectomy before the problem began to manifest, in ordel to for treatment, and mv conclusion is exactly the op- segmeni disability-related problems from underly- posite of some of the aulhors'. Of the lwo treat- ing personality pr:oblems, br"rt thank you for the ments, I prefer thtl vestibular neurectomy, because question. it is definitirre and patients are basically cured of Dr. ]ohn Shea, Jr. (Memphis, TN): I woulci like to vertigo fr:rever. Gentamicin injections are very safe con:rpliment Dr. Facer's presentation. I thought it aacl easy to do, but patients come back after 2 or 3 was absolutely brilliant. I find it ir"rteresting that years with wooziness, disequilibrium, and attacks they had 83 patients and one tolal hearing loss. of rrertigo, and I havr to reinject them. And seconrl, There are a 1ot of reports in the literatllle on people I ncver used just one in.iection. Dr" Face: mentioned rarith a {amilial sensitivity to aminog.lycoside anti- tl"rat 80?1, of patients were tr:ealed with one injectlon. biotics; the rate is about 1'11,. I harrc read about half I rt ould be curious to know the follow-up in those a dozen paper$ in the literature, and the sensitivity patients, because I was never able to accomplish is to streplomycin and gentamicin. They had one much of anything with ono injection, total hearing loss, and the minute t heard ihat, I Dr. Facer: Our mean follow-up interval is 35"6 tholghi, well, that's the l% famiiial sensitivity to months. Those patients have been followed for a any aminoglycoside. significant length of time, and they have n<-:t had It's wonderful that we now lrave neariy compl*te recurring symptoms or significant hearing loss. 31 TRANSACTIONS 2OOO / AMTRICAN OTOLOCICAT SOCIITY IMPLANTATION OF THT SIVERILY N4ALTORMED COCH L[A Andrew {. Fisltmnn, M.I}", l. Thomas Rolanil, M.D., Ceorge Alexiades, M.D., snil -l{oel L. Caheu, M.D. ABSTAACT Objective: To evaluate the feasibility, safety, and efficacy of ccchlear im- plantation in a series of palients with severe cochlear nralformations, including conrmon cavity deformities and small hypoplasti<: cochlear buds of oniy a {ew millimeters. An iniiial case report of fluoroscopically assisted implantation of a common cavity deformity is provided. Study )esign: Retrospective case review. Setting: Tertiary referral cenler. Patients: Patients with severe cochlear malformations, including common cavity deformities and small hypoplastic cochleas o{ less lhan one complete turn, were included in the review. lnterventions: High-resolution CT, MRl, plain radiography, and age- appropriate pre and postoperative audiologic and speech perceplian assess- nrents were performed in all patients, with the exception of one recerrtly im- planted individual. Fluoroscopically assisled implantation was performed in one patient. Main Outcome Measures: Nature of cochlear malformation, active inlraco- chlear electrodes currently in use, and cr:mplications and their management were documented, in addition 1o aLrdiologic testing. Results: All but one of the patients derived tangihle berre{it from cochlear implantation. C)ne patierrl who recently received ar"r in:plant has yet to be tested postoperatively, altlrough intraoperative eleclrophysiologic testing revealed that neural response telemetry and stapedial reilexes were present" Conclusions: Cochlear implarrtation can be saiely and successfully per- formed in patients with severe cochlear nralformations al experierrced centers. Reprlnt reqursts: Andrew j. Fishman, M.D., Department of Otolaryngology, New York {.Jniversity Medical Center, 550 First Avenue, New York, }dY 10016; pln" 21?-263- 7 37 3 ; { ax 772-263 -825 7. E -mail : andrew-f ishman@msn. com aa TRANSACTIONS 2OOO / AMERICAN OTOLOCICAL SOCIETY THT MANACIMTNT OF TAR-ADVANCED OTOSCLIROSIS IN THT ERA OF COCHLEAR IMPLANTATION Michnel l" Ruckenstein, M.D., M.5., F"A.C"S., Kristine O. Rnfter, M.A,, *nd Douglas C. tsigeloro, M.D. ABSTRACT Objective: To evaluate issues pertaining to cochlear implantation in patients with far-advanced cochlear oiosclerosis. $tudy Design: Prospective cohort. Setting: Tertiary care referral center. Patients: Iight adult patients (18 years of age or older) reierred for the nran- agement of profound hearing loss, the etiology af which was determined to be otosclerosis. lntervention: Cochlear implantation with a multichannel cochlear implant device. Main Outcome Measures: Benefit from cochlear implant as measured by CID sentence scores, the incidence and management of facial nerve stimulation, and technical issues pertaining to cochlear implantation in this patient popu- la tion. Results: All patients showed signi{icant imprr:vement in auditory {unction as measured by CID sentence scores and ability to engage in lelephone convet- sations. Facial nerve slimulation occurred in two of eight patients and was managed by deactivating the stimLrlating electrodes" Ossification in the basal turn of the cochlea, deiected on preoperative CT, necessitated placement oi the electrr:de into scala vestibuli in two patients and the utilization of a thinner electrode (Nucleus 24) in a third patient. Conclusion: Patients with proiound hearing loss secondary lo otosclerosis derive excellent benefits frr:m cochlear implantation. Surgical implantation can be cr:mplicated by ossification oi the cochlea, which can be detecred on pre- operative CT. Electrode activation may he complicated by facial nerve stinru- lation, which can lre addressed with prr:gramming strategies. Reprint requests: Michael J" Ruckenstein, M.D., M.S., F.A.C.S., Departrnent of Otorhi- nolaryngok:gy, Heacl and Neck Surgery, Hospital of the University of Pennsyivania, 5 Ravdin, 3400 Spruce Street, Phiiadelphia, PA 79104; ph. 215-652-6017; tax215-662- 41 82. E-rnail: [email protected]. edu 33 TRANSACTTONS 2000 I AMTRICAN OTOLOCICAL SOCIITY IS COCHLTAR IMPLANTATION POSSIBLT AFTTR ACOUSTIC TUMOR REMOVAL? Aziz Eelal, M.D. AgSTRACT Methods: Eight temporal bones in seven patients n,ho underwent acoustic tlimor removal durir-rg life were histologically examined. Special entphasis lt'as placed tn exanrining the patency of the ccichlear turns, survival of ihe spiral ganglion cells, ancl the cochlear nerve " Results: After nriddle fossa renroval of an acr:ustic tumor with an rinsuccessful attempt at hearing preservation, the cochlea was ossified, the spiral ganglion cells had degenerated, and the cochlear nerve was fibrosed" Following trans- labyrintlrirre acoustic lumor removal, the cochlear turns were filled with blood, which gradually orgar"rized into fibrous lissue and bone. Total cochlear ossifi- catiorr rvas complele within months after the surgery. The spiral ganglion cells and the cochlear nerve had almost completely degenerated. Conclusions: The possi[:ility of cochlear in:pl.:ntation after acoustic [un:or surg€ry depends on two {actors: patency of the cochlear tLrrns, and survival of the spiral ganglion cells ar:d cochlear nerve. Tlrere is progressive ostensogen- esis of the cochlear turns iollolving acoustic tumor removal. The process seems to take months to be cornpleied and is directly related io preservation of the blood supply to the cochlea. If cochlear implantation is indicated, the earlier it is perfornred the better. Follor,r,ing retrosigrnoid or rniddle fossa approaches, cochlear inrplantation may be done afier "l nronth of the initial surgery. Fol- Iowing translabyrinthine acoustic tumor removal, the internal coil may be in- serted at the time of initial surgery. Survival of the neural struc{ures in the cochlea and oi the cochlear nerve is also directly reiated to preservatinrr r:f cochlear blood supply^ Determination of nerve sr-lrvival by the promontory test rlay be a crucial prerequisite in cases with unsuccessful lrearing preservation. Reprini requests: Aziz Belal, M.D., 37 Syr:ia Street, Rouchcly, Alexanr*1ria, Egypl; fax 203-512-0280. E-mai1: alexear:@alexnet.com.eg 34t TRANSACTTONS 2000 I AMERICAN OTO|-OCICAL SOCIETy ADULT COCHLTAR IMPLANT PATIINT PTRFORMANCI WITH NEW ELICTRODT TTCHNOLOCY Terry Zwolnn, Pk.D., Paul R. Kileny, Ph.D., Slwron Smitlr, M.5., Dazuna Mills, M.5., and Mary loe Ogberger, Ph.D" ABSTRACT Objective: lrr I998, clinical trials were initiated to evaluate tlre Clarion pre- curved electrr:de plus Electrode Positioning System (EPS) in adults witlr severe "I999, io ptofound hearing impairment. ln clinical trials were initiated to assess the Clarion HiFocus Electrode plus EPS in a sirnilar group of adults. This retro- spective study evaluated the benefit of these new electrode designs and com- pared the postoperaiive speech perception abilities oi 60 patients implanted with the precurved e lectrode * IPS and 43 patients implanted with the HiFocus electrode r EPS. Study Design: All subjects participated in preoperative testing with hearing aids and postoperative testing ("1 montlr and 3 months) with either the precurved electrode + EPS or the HiFocus electrode + tPS. Ilemographic characteristics and pre- and postnperative speech perception results were compared within and between the two groups. Setting: Ths clinical trial data presented here were collected at 26 cochlear implant programs affiliated with tertiary medical centers located in the United States and Canada. Patients: Postlinguistically deafened adults who received a Clarion cochlear implant" Results: Speech perception results demonstrate the improved ccmmunication benefit provided by these two electrode designs when comparecJ with resulis ohtained preoperatively when using conventional ampliiication. A comparison of demographic data showed that the HiFocus €lroup had a significantly longer duration of deafness than the precurved electrode group. Statistical comparison of speech perception abilities showed no significant difference between pa- tients using the precurved electrode + IPS and those using the HiFocus elec- trode + [PS, aithough the mean anrJ rnedian scores for word and sentence recognition were higher ior the HiFocus + EPS group. Reprint requests: Terry Zwolan, Ph.D", University of Michigan Cochlear Implant Pro- gram/ 475 Market Piace, Building 1, Sriiie A, Ann Arbor, MI48108; ph. 734-998-8119; fax 7 34-998-81 22. E-mail: zwolan@un:rich.edu 35 DISCUSSION DISCUSSION PERIOD V: IMPLANTABLT DEVICIS Papers 1 4*17 'Ihis rinder- Dr. C. Cary ]ackson {Nashvilte, TN): set of and our evaluation. The six patients a11had papers is nnw open for discussion. gr:ne primarv stapedectr:my previously. We ftlund Dr. Mansfield Smith (San .fose, CA): i'd like tc; no evidence of any l-:rone audition on examination. see aboui 30 seconds of the video that lfr. Fishman They had iongstanding disease, anrl we had no was sho'oving; \{'e were just gelting into it and he good evidence to suggest ihat there wculd be a had to stop. positive response to revision stapedectomy' So, af- I)r. Andrew Fishman (Nr:w York, NY): We pre- ter discussing the situation with each patient, ar:d curved the tip" Here's the common cavity in the based on our somewhat poor resuits will: revisj.on internal auditory canal" The important aspect of us- procedures in patients with far-aclvanced otosclero- ing this lluoroscopic t*chnique is to arroid inserting sis, trt e decided to pr:oceed r,r,ith a cochlear implan- it right into the internal auditcry canal, which n'e tation. did on the previous common cavity. Here the de- Dr. |ohn MeElveen (Raleigh Durham, l'IC): Dr' vice makes a complete turn. It probably snakes Fishman, what particular approach did you use for around to the back of the hypoplastic semici::cular the commorr carrity malformations as well as the canal. Here's the nice curve of the device, right other maiformations? here. And here are the common cavity, the internal Dr. Fishrnan: A surgical approach is not dissimi- auditory canal, and the final configuration. lar to a standard cochlear implalt procedure per- Dr. Bradley Welling (Coiumbus, OH): There formed through a facial recess with the canal w'all set:rns to be an unusually high failure rate fo:: these intact and uiilizing preoperative CT to determine deyices i:r the rnalformed common caviiy. Could the position lor thtl cochleostomy. 5o, in comparing you comment on lhat? the surface features, if you see scmething like a Dr. Fishrnanr There are tttro device failures. Nei- common r,vinclow depression, or perhaps a round ther of them har,,e to clo r.vith electrode problems. window or an or,al window, you can use those fea- They harre lo do with the receiver stimulator type r:f lures ts delermine the locaiion of the cochleostomy. device failure. It's coincideniai that ihose two hap- Dr. h{cXlveen: Did you do lacial recess on all of pened to be in matrformed cochlean, but they were the common cavilies? I ask because you rnight not specific to electrode malfunction. There does avoid problems with advertently coursing facial seem to be a higher number of short-circirit elpc- nertrres if you go eiirectly into the area of the lateral trodes, which you would expect from the {act that semicircular canal using the kansmastoid lahyrin- lhese are inserted inta a kinkecl or a looped or a thotr:my approach. I don't know whether you have spiral configuraiion, but those are programmed considered that. or,rt, and they are usually left with an average o{ 10 Dr, Fishman: I have seen it. Most of the aberrant or 12 working electrodes to use in ihe program facial nerves were still identi{iable in a case in map' which the facial nerve was entirely inferinr to the Dr" Richard Wiet (Chicagc, iL): This question is common caviiy. Jt was not iclentifiecl, but the for Dr. Ruckenstein. iI you were confident nf your chorda was identified, and there is ample exposure diagnosis of far-advanced otosclerosis*and I realize (or view) ol the mesotympanum, especially if you that's a very rare problem-r+'hy did you not eon- take down the incus bar. We do tend to pui a little sider primary stapes surgery in six of eight pa- stimulator over the surlace oi the promontory just tients? In other words, how did you arrive at ihat before dril1ing, just to make sure that nerve fibers manasement decisi*n? are not splayed over the surface o{ the prortontory. Dr. Michael Ruckenstein {Philadelphia, PAi: Dr. Noel Cnhen il'}en, Ynrk, NY): A comment for Thank you, Dr. Wiet" I want to mention that yor"rr Dr. Belal: We firsl reported lhe ule of a cochlear paper v/as one of the papers we care{r-rl1y reviewed implant {ollowing acoustic neuroma surgery in before deciding on management strategy. The de- 1991, and the patient is stili using his cochlear im- cision was made in conjunction wiih lhe patient plant. F{e is a lawyer and on the telephone all day. Jb DISCUSSION Dr" Anthony De La Cruz (Los Angeles, CA): Dr. the internal auditory canal. Usually those elec Ruckenstein, what made you decide not to do a trodes need to be turned off from the map be- stapedectomy in the other ear? cause of facial nerve stimulation, so it effectively Dr. Ruckenstein; Again, it was the absence of a11ows us fo have fewer electrodes active in any hint of bone audition in the other ear. A second lhe common cavity. So it's jusi a sr"rboptimal place- consideration is rvhen the eleclrode goes into meR.t. 37 TRAI\SACTIONS 2000 I AMERICAN OTOLOCICAL SOClrrY HEARINC RIHABTLITATION USINC THE BAHA BONI-ANCHORID HEARINC AID: RESULTS lN 40 PAT NTS Lswt'ence R. Lusfig, An,D' , H Alexmder Arts,l\4.D.', Dersld t. Brnclcmnnn, M.D.'\, Hownril F f rincis, M"D"' , Tittt Molony, M.D.a, Cli-ff A Me gtt'intr, M.D.'t, Gnry F. Moore ,M.D. F.A.C,5.6, Ksren M-Mottre, M"A",' , Trish Morraril, M"A'|., William Potsic, M.D.S, Jty T, Rubenstein, M.D.e, Shavwilln Srircildy, M.5.,1 , Chnrles A. Syms III, M.D.: F "A.C.S.'to, Gail Tsksltsshi, Da.aicl Vernick, A4.D.11 , Phittiyt A" Waclrynt, M.D., F"A.C.S.i2, plut K. NiTtnrko, M.D.1 ABSTRACT Objective: To evaluate the experience of the iirst 40 patients who have undergone aLrdiologic rehabiiitatiorr rvith the BAHA (Bone-Anchcred l"learing Aid) in the United States. study Design: Multicenter, nonblindecl, retrospective Casc serie's. Setting: Twelve lertiary referral medicai centers irr the United Siates" Patients; Patierrts eligible ir:r t3AlJA device implantation were those with hearing loss and inability to tolerate a ccnventional hearing aid, with br:ne conduction pure-lone average levels of 50 db or less at 0.5, 1, 2, ar:d 4 kHz. lntervention: Patients who nret aLrdiologic and clinical criteria were im- planted with llre [3AHA Bone-Anchored Hearing Aid (BAHA, Entific Corp)' Main outcome measures: (1) Preoperative air and bone conductiorr tlrresh- olds and air-bone gap; (2) postoperative BAHA-aided thresholds; (3) hearing improvement as a result o{ inrplar"rtation; (4) imFrlantation comp:licatinns; and (5) patient satisfaction. Resulls: The most conrmon indications ior implarrlation incluclecl clrronic r:rtitis media ancJ/cr rlraining ears (18 patients) and external auditory canal sle- nosis or aural atresia (7)" Overall, eaclr patient had an avsrage improveme nl rlf 32 dB * 19 dB with the r:se of tlre BAHA device. Closure o{the air-bane gapto within 10 dB of the preoperative bone conduction threslrolds (postoperative BAHA-aided threshclicJ vs. preoperative bone ctinduction threshold)accurred in 32 patients (80,/,,), while closure to within 5 dB accurrecJ in 24 patients (60o1,). ln .l 2 patients (30%) there was "overclosure" oi the preoperative lrone concjuc- tion threshold of tlre better hearing ear. Complications were lin'rited to local infecticn and inflammation at the implant site in three patients, and failure lt: asseointegrate in one patient. Patient response to the implanl was uniiormly satisfactory. Orrly one patient reported dissatisfactiorr with the device. Conclusions: Thc BAHA device provides a reliable and predictable adjurrct for audilory rehabilitation in appropriately selected patienls, offerirrg a means of dramatically improvirrg hearirrg thresholds in patienls witlr conductive or mixed hearing loss who are otherwise r;nable to benefit from traclitional hearing aids. 38 TRANSACTIONS 2I}OO / AMTRICAN OTOLOCICAL SOCIETY tDepartrnent of L)tolaryngoiogy*Head and Neck Surgery, johns Hopkins University, Baltimore, MD 2Department of Otolaryngology*I-{ead and hJeck Surgery, lJniversity of Michican Medical Center, Ann Arbor, N4I 3Horrse Ear Clinic, I-os Angeles, CA al)epartment of Otolaryngology*Head and Neck Surgery, Ochsner Clinic, bJew Or- leans, LA sDepartment of Otolaryr"rgokrgy-Head anri Nleck Surgery, Unive:sity of Massachusetts Medical Center, Worcester, MA $Unirrersity cf Ncbraska Meclical Center, Omaha, NE TCharleston HNT Associates, Challestnn, 5C nchlldr*n's Hospital of Philadelphia, Philadelphia, PA eDepartr:rent of Otoiaryngology:Head and NEck Surgery, University of lowa Hospi tais and Clinics, lowa City, IA loDepartnrent of Otolaryngology*Head and Neck Surgery, Wiiford Hail Metlical Cen- ter, San Antonio, TX lrDepartment of Otolaryngolog,-Head and Neck Surgery, Harvarel Medical School, Boston, MA rzDepartment of Otolaryngology*Head and Neck Surgery, Medical College of Wis- consin, Miiwaukee, WI Reprint requests: l.awrence R" Lustig, M.D., Division of Otology, Neurotology and 5ku1l Base Surgery, Department of otolaryngology*Head and Neck Surgery, ]ohns Hopkins School of Medicine, ]HOC, 6th floor, 601 l{o. Caro}ine Street, Baltimore, MD 21287; ph. 410-955-6420. 39 TftANSACTTONS 2000 / AMERICAN OTOLOCICAT SOCIrrY UPDATT ON CONSIRVATIVE MANACIMTNT OT PATIENTS WITH ACOUSTIC NEUROMAS Dick L. Haistnd, M.D,, Grorgr A. ltAelnik, M.D", Eulent Manilkaglu, M.D., Csthleen A. O'Cotnwr,l\,4.,5., sncl Ric/mril l. Wiet, M"D., F.A"C.S. ABSTRACT Obiective: To update our "1995 experience with conservative management af acoustic neuromas {ANs). Study Design: Retrospective chart review. Setting: Private practice and tertiary care referral setting. lntervention: O{ 600 patients with an AN, 102 were treatsd witlr a "wait and scan" treatrxent option" At least two nragnetic resonancc imaging (MRl) studies were required in all patients. N'lain Outcorre Measures: Change in tumor size over time, and clinical sympton"rs (hearing slatus, linnilus, balance disturbance, aural fuliness, verligo, headache, and facial pain, nurnbness, or weakness). Results: The average follcw*up time in the 102 patients was 28.5 months. ln 45 t44'y") of tlre 102 patierrts, lhere was a change in tunror size, which grew on ;rverage 2.'17 mm per year, ln the remaining 54 patients (53%), nn growlh was demonstrated on a m€an follow-up of 28"5 months. ln three patients the tumor -102 shrank. Of tlre paiients nranaged conservatively, SS (84%) reported hearing loss, 67 {6{rol,) tinnilus, j7 (36'y,} balance distr:rhance, 29 (Zt\tk) aural fullness, 2& {27'fo) vertigo, 7 {7'/") headache, 4 l4'f,,) facial numbness, 2 (2%) facial weal Reprint requests: Dick L. Hoistad, M.D., 11100 Central Street, Suile 610, Evansto:'r, IL 50201; ph. 847-570-1360; tax 847 -773-5360. E-mail: [email protected] 40 TRANSACTIONS 2OOO / AMIRICAN OTOLOCICAT. SOCIITY COMPARISON OF THT KI-6/ AND C-TOS STAININC PATTIRN IN CLOMUS ]UCULARI AND CLOMUS TYMPANICUM TUMORS Moha*rmecl Mujtahn, h[.D., l. Tkorms Roland, M.D., Dennis G, Pappns, M.D., and Dean E. Hihnan, Pk.D. ASSTRACT Hypothesis: The size oi the jugulotympanic paraganglionra {JTP) is directly related to the density oi Ki-67 antibody- and c-fo.s antibody-la[:eled cells, and is indicative of tumor aggressiveness" Background: Jugulotympanic paragangl iomas are usually slow-grerwing be- nign tunrors of the temporal bone; however, some tumors may show aggressive growth rates and l-:econre malignant" ln this study, we utilized c-fcsand Ki-67 antibodies for labeling cells in the active phase of replication. The density of c-fos- or Ki-67-labeled cells was compared to tumor size for determining a possible relationship to the rate of growth. Method: Nine surgical tumor specimens that included both the glomus tym- panicum (CT) and glomus jugulare (CJ) were investigated using immunohisto- chernical ancJ ultrastructural analysis. Tumc;r sections Iabeled with Ki-67, c-fos, y-tubulin, and S-100 antibodies were analyzed using a light nricroscope inter- faced with a computer-based mapping system. UltrastructLrral arralysis of the tumor sections was performed to cr:mpare morplrological {eatures. Result: Large-sized and recurrent glomus tumors (most aggressive types) had a higher density of Ki-67- and c-tos-labeled cells with a low density r:f the ry-tubulin-laL;e lEd cells than the small-sized nonaggressive tumors" 1n addition, rnalignant and recurrent glomus lumors had an increased numlrer of mitochon- dria as compared to the small-sized tumors. Conclusion: There is a positive correlation l:elween the aggressiveness of glomus tumors and the density of Ki-57- and c-fr:-s-labeled cells, but a negative correlation for density cf 1-tubulin-labeled cells. An increased number of cel* lular organe lles suclr as mitochondria might reflect the rapid tumor growth rate. We conclude that Ki-67 and c-fos antibodies are indicative of a faster growth rate and susceptibilily for recLrrrence in glomus tumors. Reprint requesls: Moharnmed Mujtaba, N4.D., Department of Otolaryngology, TH-513, New York University Medical Center, 550 Firsl Avenue, New York, NY 10016; ph. 212-263 -7 430; f a x 277-253 -5240. E-rnail : sup errnoe 1 @excite. com 4I DISCUSSIOF'J DISCUSSION PERIon Vl: HTARINC IOSSIINNIR rAR Papers 1 B*21 Dr. C. Gary ]ackson (Nashvil1e, Tl{)r These pa- Either we obser'",e these patients or, depeuding on ptlrs are nor,v open {or discussion. the institution in which they are beilg treated, thel' Dr. Michael Seidman {Detroit, Ml): Tlris ,1r.res- often recc.ivc postoperative radiation therapy. We tion is for iJr" Hoistad. I enioved vour talk Lrr,rt lrope that some of thc data we are acquiring will might question the age cutoff ol60 years for a "wait help r,rs decjde which of thosc patients should be and scan" approach. The average life span in ihe offered rarliation lherapy earlier rather than later. Unitrd $tates today is 75.6 years, r,.,hich gives this Dr. Donald Kamerer (Fitlsburgh, PA); Dr. lumor 16 years to grora-. lrlow, if you scan every 6 or I-,ustig, I enjoyed vour paper vr:r;, much. We cor 12 months, you will probably catch something, brri t;riniy agree t.hat the bsne-anchcred hearing aid has il you go from a S-mm tun:lor-rvhich I thir-rk is rea- a place. Yor-r reporterl oirly one failure at osseoinle- sonable to n atch*and find on the next study tirat it gration, and i was a little surpr:ised by your waiting is 1.5 cm, t.he risks increase slgnificantlr., and the time, only 6 weeks Lrefore hookup. In our sma1l se* ethics r:f this situation becorne qlrestionable. I cer- ries we have lvaited 3-4 months. Could you cofi-r- talnly offer 55- to 60-year-old paiicnts a "wait and ment nn that? scan" choice if lhe tumors are small, but I uronder Dr" Lawrence lustig (Baltimore, MD): We used 6 whetl-rer their average lile span should be a consid- weeks because ilrat's r,l,hal the Srt edish groups eratir')n. have used, and they are the ones r,l,ho developed Dr. Richard Hoistad (Evanston, IL): if l under:- osscointegratirxr, sc; we followed their ieacl. 'fhe one stand vour question correctly, my response is that patient in n hom osseointegration ciid not occur even younger people might preser"lt vvith a tr:rnor was the your:rgest patient in our series. T'he Sll,edish and end up in the same predicament. lJo y*u u,ant groups aro nllw recommeflding 12 weeks for ado- to comment onel mort: time si: t.lrat I can trv to ex- Iescents and youngcr patients Ior osseointegration. plain? ln adults, 6 weeks is adequate, but in adolescents or Dr. $eidman: Mrlr uuly crxnmcnt is that 60 vears younger pediatric patients, at least 12 weeks should seems aw{ully youns lrrhen ttrre a\rerage lif* span is btl allowed be{c}re osseointegration. now 76.6 year:s. Dr. Julian Nedzelski (Toronto, O|'J): With re- IJnidentified Speaker: Can i help you out, Dick? spt:ct to Dr. Hoistad"s paper, 1 would jr-rst like to *This issue o{ wait and scan can be ;rpplied to make a plea that irrespective of what l,rre as a fra- young people. Thele doesn't need io be an age cul ternity decide to use as nreasuring guidelines rt'ith off af 6ll years. The point is, if you are diagntrsing respect tci tunror growth, let's adhc.re to those peopte with 2-mm tLunors thal are .intracanalicular, guiilelines. l'm chagrined that r,ve r,r,ould decid* therc is time. I tirink that's an arbitrary lule that is that the tumor is growing or nlt growing on the estalrlished but perhaps not appropriate. We r,vould basis of a slngle moasurement, whrch seerns to btl want to clarify that. the longest dimensi*n of the tumor. There is ample Dr. Bruce 6antz (loll'a City, lA): Dr. Muitaba, 1 precedent in the literature Ior clecirling hon, we will enjoyed your paper. We d* encounter tllese aggres- measur€ tun'iors. ()thenrrise, r,rrhat rve report as sive tumors arrd r,l,e don't know lr,hat to dr: with growing $r nongrowing turnors will be e\ren more yariable, thtm. What do you do at hlYU r,r,hen )zon find an and we nr:ed some data that are at least aggressirre turnor? I)o you alier your postoperatlve uniform. manageil-lent $trategy, and lt hat is lhat manage- Dr. S.ichard Wiet (Chicago, IL): I'd like some rnent strategy? clari{ication on the paper on imnlunohistochemical Dr. J. Thomas Rowland (l{er,r'York,l{Y): We are erraluation of glumus turrors. Will your paper shed not sure, because our data are preliminary, but in any light on lhe emerging reports of gamma knife general, if we have a tumor that is vcry aggressir.e, treatment for glomus tumors lrer$us standard ra- r,ery invasive, and has a lot of carotid arter,v in- diation? Will yorr have informaiion in that area? volvement, u.e clo not sacrifice the carotid arteries. There are recent reports that in irrdividuals with 42 DISCUSSION large glomus jugulare tumors, the gamma knife Dr. Lustig: Al1 the patients with otosclerosis or may effeciively retard tnmor growth" lt doesn't re- conductive hearing loss irad bilateral hearing loss" move the tumor, of course, but it is norv being used Many of these patients hac{ bilaleral mastoid bowls for slort'ing tumor growth. Does yor:r paper give us and bilateral chronically draining ears lhat could informat:ioir to help us with management strate- not be fixed, and as a result they could not wear a gies? Can you commt:nt on that? hearing aid on either ear. That was probably the Dr. Itowland: l'm going to help out on this one. mosl common indication for implantation. To an- This is just prelirninary infor:mation; these are post- swer the second question, the mr"rst common uni- operative evaluations. Perhaps you artl referring to lateral indication was a patient:.vho underwent ex- the possibility that crre might w;rnt to biopsy the ternal auditory canal closure following a skull base tumor to get information, and then decide on treat- procedure. Hearing in the conkalateral ear was ment preoperativelv. In general, we have not been fine, but the patient didn't have any hearing by air using the gamma knife as a treatmeni option in pa- conduclion on the bad side, $o we felt lhat was an tienls n'iih glomus tumors. excellent indication to proceed. Ali of those patients Dr. Lawrence Duckert {Seattle, WA): Two ques- had subjectively improved results and were very lions for Dr. Lustig regar:ding thc BAHA" First, is huppy r,vith iheir device. thrl BAHA currently FDA-approved for use in the Dr. Dudley Weider (Hanover, NH): What u.as pediatric populaiion? Second, do you have any idea your maximum overclosure? what your audiologist char5;es for the device itself? Dr, Lustig: The maximum overclosure was aboul Dr. Lawrence Lustig: The answer to both ques- 5 dB. tions is no. The BAHA is not approved for use in Dr, Steve Telian (Ann Arbor, Ml): Can you com- the pediatric population unde::5 years o{ age; that ment on tinnitus suppression with the BAHA? issue is being w'orkecl on dght now. |ohn Nepat:ko, Dr. Lustigr I have ro data at all indicaiing that lvhr: is also one of the authors of the study, is w'ork- the BAHA does suppress tinnitus, and we had rro ing with Anaifik io try to get thai approrral. And no, reports from any oiher palients that their tinnitus I don'i knorr what rny audiologists charge. was improved by the device. So 1 don't think i Dr. Brad Pickett (NM): Which of your patients would recommend it at this point for linnitus, but it had bilaieral mixed or conductive hearing 1oss, and might be something to look into in the future. For how did unilateralitS, affect your indications lor the present, I have no data to suggest that it helps surgery and vour results? tinnitus. TRANSACTIONS 2O$O I AMERICAN OTOTOCICAL SOCIETY TTANERCIPT THTRAPY TOR IMMUNT-MTNIATTD COCHLIOVTSTIBULAR DISORDIRS: PRELIMINARY RTSULTS IN A PILOT STUDY Hyan K. Clrol, M.D., ]\4.P,H., Uennis S. Poe,l\tl.D., nnd Mshboab U. Rahtnan, M.D., pk.D. ABSTRACT fibiectiver lnrmune-nrediated cochieovestibular disorders {lMCVDs) cr:n- linue to presenl a management challenge to the otolaryngologist. Antirheumatic agents, ccmmonly enrployed for lMCVDs, are associaled with varial:le efficacy and sonretinres with serious sicie e{fects. ln this raport, we describe prelirrrinary results in patients with IMCVDs treated rvith etanercept, a TNF-1 rectlptor blocker recently approved by the FDA for the treatment of rheumatoid arthritis. Study )esign: Retrospective case series. Setting: Terliary i:are hr:spital. Patients: Tw'elve palients suspected r:f having IMCVDs unresponsive to con- ventional therapies or who r"levelopecl side effects to conventional therapies. lntervention: Etanercept, 25 mg, given by suhcutaneous injectiorr twice a wt:ek. Main Outcome Measures: Assessrnent of hearing change by air conduction pure*tone audiograms anci/or word discrimir:ation. when present, veriigo, tin- nitus, and aural fullness were ilssessed as w,ell. Results: Follaw-up in excess o{ 5 months ivas available for all patients (range, 5*l2 nronths). Ileven (92Y,,) of I 2 patients had improvement or stabilization oi lrearing and tinnitus; 7 {SS%) oi B patients who had veriigo ancl B (89%,) of I patients who h;rd aural fullness cxperienced resolution or significant improve- ment in their synrpioms. The l:enefit persisted until t]re last visit i5*12 morrths after starling elanercept). ln one patient the initial dramatic improvement de- teriarated after 5 nranlhs" The patient's hearing was rescued and stabilized with the addition of leflunomide to etanercept. Three other patierrts needed a second antirlreumatic agent to stabilize tl":eir hearing. There were no significant side effects from the etanercept therapy. Conclusions: Ou r lirn iterd data suggest ihat etanercept iherapy is safe and may be efficacious in carefully selected patients with lMCVDs, at least on a short- ternr basis. These preliminary eificacy and safety results are encour.iging enough to warranl {urther follor,v-up and studies fr:r better deternrinatiorr of the poiential clinical utility, od etanercept fr:r lMCVDs. Reprint requests: Mahboob U. Rahman, M.D", Ph.D., Arthritis Associates, Massachu- setts Ceneral Hospital, 15 Palkman Street, Bnstorr, MA 02114; ph.51V-726-7938; {ax 61V-721-2718. Jt" TRANSACTIONS 2OOO / AMERICAN OTOTOCICAI SOCIETY RISK TACTORS TOR HIARINC LOSS IN NEONATTS Stilianos E. Kottyttskis, M"D., Plt,D., lohn Skoultts, h,4.D., Dintre Phillips, M.5., snd C. Y.loseTth Chang ABSTRACT Obiective: To identify pctential risk iactors {or neonatal hearing loss that are not included in the current varial:les recognized hy tlre Joini C.ommittee on lnfant Hearing (JCIH). Methods: A series o{ conser:ulively born r:eonates with risk factors {or hearing loss based on the 1994 JCIH registry were screened prospectively. There were 110 subjtcts with hearing loss and 636 sulrjects without hearing ioss. Data collected as poie ntial risk faciors for infant hearing loss included not only those on the JCIH list but also others that we be lieved could be significant. The iniant hearing screening was performed on each subl'ect using auditory brain stem testing. Statistical analysis of data was performed using the chi-squared lest. Results: ln addition to the variables listed by the JCIH, we identiiied 'tl other risk {actors that were associated with hearing loss in our neonatal populaticn: length of stay in the iniensive care unit, respiratory distress syndron":e, reirolen- tal fibroplasia, asphyxia, nleconium aspiration, neurodegenerative disorders, chromosomal abnornralities, drug and alcohol abuse by the motirer, maternal diabetes, mLrltiple births, and lack of prenatal care. Conclusion: This study identified f i risk faclerrs in addition to those currently on the high-risk registry published by the lClH for neonalal hearing loss. The inclusion of these additiorral risk {actors in neonatal screening programs may inrprove the detection rate of neonates with hearirrg loss. Further study will be needed to determirre whelher^ inclusion of these additional risk factors in a hearirrg screening program can provide an eflicacious allernative to the use of univcrsli irr[ant st rcening. Reprint reqr:esls: Stilianos E. Kountakis, M.D., Universily of Virginia Medical Center, P.0. Box 1008, Cirarlottesviile, VA 229U6-0008; ph. 804-246-6522; fax 8A4-743-65?2. E-mail: sekSn@virginia"edu 45 TRANSACTIONS 2OOT} / AMERICAN OTOTOCICAL SOCITTY LIDOCAINT PIRTUSION OF THT INNIR TAR PLUS IV LIDOCAINI TOR TII\NITUS {okn l. Shm, {r", M.D., nnd Xisnxi Ge , M.D. AsSTNACT Objective: To determine the results oi lidocaine 6ler{usion oi the inner ear plus intravenous (lV) lidacaine for intractable tinnitLrs. Study design: Retrospective case review. Settingr Oto i ogy/neu roio logy referra I center. Patients: Lldocaine perfusion of the inner ear plLrs lV iidncaine was per* formed on 7"1 ears of 63 patients wilh irrtractable tinnitus. Patients were fol- lowed up for 1 nronth to 1 year. Intervention: Approximately 0.5 mL of hyalurt:nan (Anrvisc) con{aining 20 nrg of Iiciocaine per nilliliter was injected intr: the re;und wincJow niche. The patienl remained wilh the operate ear up while receiving 500 nrg of lidocaine lV over 2 hours" The procedlrre was performed on each of 3 cr:nsecutive days. Hearing and spcntaneous nystagmus were tested on tlre second and third days. Main Outcome Measure: Subjective evalualion r:f tinrritr.rs by the patient. Complete relie{ was indicated by no more tinnitus, partial reiief by occasional troublesome tinnitus, and no relief by tinnitus remaining lhe same. Results: Conrplete or partial relief of tinnitus was achieved in 35 (70%,) of 50 ears within 1 month, in 20 (76.9"/,,) a{ 26 ears within 3 months, and in l0 (S3.3%) of 12 ears within 1 year. Hearing remained the sanre ir": all paiients. Ter:rporary paralytic spontaneous nystagmus nccurred in l2 ears, irril;rtive in 21 rars, and no nystagn-lus in 25 ears. Canclusion: Lidocaine perfusion of the inner ear plus lV administration oi lidclcaine is a safe and Effective treatment {or intractable tinnitus. Reprinl requests: ]ohn J. Shea, _fr., I\,{.D., 6133 Fopiar Pike, Memphls, TN 38119; ph. 901-7 61-9720; fax 901-683-8440. E-mail: [email protected] 46 TRANSACTIONS 2OOO / AMERICAN OTOI.OCICAL SOCIETY ROLI OF IMACINC IN THE CLINICAL DIACNOSIS OF INNER IAR DISORDIRS Araind Kunlnr, !\4.D", Mnhmood Mnhfee , M.D",Scotf W. DiVentrr., M.D., and Hcm Soo Bae, B.S. ABSTRACT Obiective: ln the clinical setting af unilateral hearing loss, unilateral tinnitus, dizziness, and facial paralysis, modern imaging lras effectively served to "rule out acr:ustic tumor." However, in the mafority of patients, no tumor is found, arrd tho caustl of the symptoms renrains unclear. This stLrdy sought to demon- strate the diagnostic potential oi advanced imaging studies for disorders of the inner ear and adjacent nerves. Study Design: Retrospective case review. Settingr Tertiary referral center. Patients: lndividuals presentirrg with Lrnilateral hearing loss, unilateral tinni- tus, dizziness, and/or facial paralysis. lnterventions: Diagnostic review of palients' clinical, audiologic, vestibular, and imaging studies. Main Outcome Measure: Comprehensive clinical data in patients with uni- lateral inner oar symptoms were correlated with results of advarrced imaging. Methods: Comprehensive clinical clala are correlated with the results of ad- vanced imagirrg studies, and specific inner ear diagnoses were established. Examples of such diagnoses include hemorrhage intc the inner ear, cochlear derrdritic demyelination, cochlear otosclerosis, inflammatory lesions r:{ the me- aial and intralabyrinthine f;lcial nerve and inner ear, intralabyrinthine schwannoma, and endolymphatic sac tumor. Conclusions: When advanced imaging of the inner ear is correlated with conrprehensive clirrical data, speci{ic pathologic entiiies of the inner ear can be tonfidently diagnosed. Should all patients with unilateral inner ear symptoms undergo this cr:stly imaging procedure? More data are needed to answer the question. A multicenter study o{ patients with unilateral inner ear symploms would prcvide data that coLrld be used in developing;lppropriate guidelines. Reprint requests: Dr. Arvind Kumar, M.D., University of Iilinois at Chicago Eye and Ear Infirmary, 1855 Wesl Taylor Street, Chicago, lL 6A61,2; fax 312-996-tr534. E-mail: [email protected] 47 DISCUSSION DISCUSSION PIRIOD Vll: HIARINC LOSS/INNrR IAR Papers 22*25 Dr" C. Gary jacksr:n (Nasll,ille, '[1\l): Thcse pa- to methplrexate. One of or"rr palients had a dramatic pers are now open for discnssior-1. response wiil-rin 2 weeks" She was using hearing Dr" Mark Gustalson {Cincinnafi, OH): l lva$ \rery aids, and her hearing impr:oved so rnuch that alter interested in Dr. Shea's papor. Some r:f the previous 2*3 weeks sl-re clid not neecl a hearing aid anymore. paper$ on lidocaine perfusion in the middle ear Your other question n,as speech discrimination" spacc nrenLioned a lot of poslprocedurc vertigo r"le- Yes, we see thai. In fact, some of our patients that cessitaiing hospitalization. I was wonde ring if you r:lid r:ot show significant in.rplr:rrement in pure tone saw this type of impact. A1so, because of the heart had dramatic improvement in speech discrimina- monitoring yr:u talked aboul, werff you keeping the tion. One of or,rr patients had only 34lo/o speech paiients in the hilspital. or doing the procedure in eliscrimination hefore the trealment was started, ihe o{fice? atd within 3-,t r,r,eeks it r,vent up to 94'%, aithougi: Dr" John Shea (Memphis, TI{): Yes, they nll ex- the paii.ent contir"rued to rrtled a hearing aid, because perienced significar:t rrertigo after the treatment for his pr"rre-tone levels wcre low, in the 40- to 50-dB the first couple of hours. It's interesting becanse the 1alrge. patients we have treated have not had anv facial Dr. Larry Duekert (Seattle, WAi: I harre a cauple weakness, and it is also strange that we a1u,,avs pro- t:f comments regarding Doctor Shea's paper" I'm voke a rrery stron$ spontarreous nvsta5;mus. Some- afraid I do not share his errthusiasm for thr: use tinres the nystagr:nus is away from the treateri ear, of IV lideicaine*at least I don't have any experierrce but in about half lhe cases it is torr,,ar:d the treated with profr:sion. Some time ago, ary ar-ldiological ear, so something ciifferent is going clrr. The dizzi- eolleagues and I condncted a r:1ouble-blind study ness lasis only a short while, about 2 hours. But it is using iV lidocaine, and we found lhat hy crrmpari- almost alr,vays qnite serrere. son r,vith the conlrol grorlp, there was no signi- Dr. h,Iohamed Hamid (Cleveland, Ol-i): I have a ficarrt difference. ln some cases the patients who question for Dr. Poe and his grr:up. tr realize that the rcceived the iV lidocaine said their tinnitus got study is a pilot stucly. Mv question is, havr: you had worse. ll'hat rc,as the first half of thr etudy; the re- patients treated with methotrexate, .rnd carr you sults ll,ere clescribed here, before this Society. The cornrnent on lhe results of b*th? $econd, in my ex- next year u,e recalled our patients and told thr:se perience speech discrimination is also vt:ry re$pon- who had received thn placebo that they rvould he siye to this particular treatment. Irr fact. we havc getting the drr:g in the new studv. But instead, we already increased speech discrimination {r'ol:r 20'/,, garre them the placebo again, and on that particular io 70'X,*80'/o with prednisone and nlethotrcxate. Is uecasion, many o{ them got better, and imples- ihat ihe case witir Entanercept? sively so. So we concludeci that to a great degree, Dr. Hyon Choi {Bosto:r, MA): We have many the e{{ect*if there was an effect-was a placebo ef- patienis who are on methotrexate, and also some fect. pat.ienis on anothr:r lnethatr:exate-1ike nredica- Dr. Shea (Memphis, TNJ): 1 anr surprised, but nut tion caller:l Araba" lnlerestingly, the lesults u,e totally surprised, at 1rs11 results. I think it's possible saw in thc mediated cochlear vestibular disorder to prove anything if yor,r slartlviLh the right stlt of parallels our experienct: with the treattrent uf rheu- patients and the rigtrrt rnirrd-set. My paper re{erred matoid arthritis. ln rheumatoid arthritis, the expe- to about 10 articlEs jn the liierature that do report rience r,r,ith methotrexate is very ]ong, about 30 beneficial effects of }V lidocaine, includir"rg a sclics years. Thc patients get better, br-rt after some time of paper:s by Melding and his grorlp in Auckland, the efficacy cf nrethotrexatc diminishes, ;rnd it is tr'm fascinated by what lou have to say" Our expe- nerrer 100%," Patients show about 6il'X,-80% im- rience is exactly the opposite. The basic prenrise prr:ven:enl, ancl it takes 3*4 monlhs to achieve full that you have to nse in dealing with these people is effect, similar:ly lvith Araba. Bnt xrith lintanercept tl"rat they lxive a drsorder that is mostly located in ar Ambrel, the efficaev is extremely high compared tire ear, and then in the Lrrain, a1ld u/e are beginning 48 DISCUSSION to understanci the brain function of tinnitus a lot from 80 mg ia 10 and 5 mg. Wc hope we will be able better. I think there will be drugs coming lhat we to taper tl:em off compleiely. can use to treat the clepression. The ol1e we are most Dr. Manohar Bance (Toronto, ON): My questir.rn interested in, in adcliiion to lV lidocaine, is ca11ed is on lhe same topic. Do you have any patients in Iffexor, which increases ihe body's r-rptake of both your group in whom sleroid treatmenl failer1, and serotonil and dopamine; it has a dramatic ef{ect. l do you have any experience with salvaging steroid had oire man with tinnitus that was not hclped by failure with Intane:cept? 1s there a possibilily that anything wr: did" iV lidocaine and all these things patients in whom steroid treatment fails could be wouid heip him for a wl"rile, and then he'd come ef{ectively treated with Etanercept? back. We put hirn on Effexor, and he is a dramati- Dr" Choi: All of our 12 patients had a good re- caliy improved person. So this is shotgr-rn therapy; sponse to prednisone; however, in our experience it isn't just {V lidocaine. But the lV lidocaine is a with Dr" l)eru"ris Poe. we had a few patienls who ei- dramatic treatment" I couldn't disagree with your ther had a questionable response to Prednisone or did results more, but, is as I said vesterday, that is whv not have a good respollse to prednisone br-rl had other they make chocolate and vanilla-it's a matter of indicaiions suggesting an auioj.mmune process. opinion. Fr:r example, one of the palienls did not respond Dr" John Lisek (Columbus, OH): This question is to steroids but did have ihe entire HSP 70 antibody for Dr. Choi. What creiteria rlid yor,r use to deter- pr.lsitive, $o r /e tried metholrexaae and gi:t similar mine improvement in patier:rts on Entanercept, a;rrl results, even though the patient did nnt respond tcr were those rr:sponses sustainecl? Were the sleroids prednisone. F{owevel, we have also lreated some continued cluring lhe treatment? patients w'ho were unresponsive tr: prednisone and I)r. Hyon Chai: We ustld the Amcrican Academy subsequently unrespon$ive to methotrexate. We do criteria for tl're improvement or stabilization of not have any experience with patients who we:e hearing, which include more than a 10-dB improve- unresponsive io prednisone then being treated with ment.in pure tone in two consecutive waveiengths Entanercept" li is a very expen$ive meclication, and or more than a 15-dB improvemena in one walre- we are using it off siudy, as ii is FDA-approved length or mol:e than 15% improvenent in the word only for rheumaioid arthritis, so we have to make a discriminatiorl score. When we started the patients gcod case before we use Entanercepi. As I rnen- on tinnitus therapy, len oi the patients r.vere still on tioned, 58?1, of our patients had tried methotrexate, very high-rir:se prednisone. Of lhose ten, eight were Cytoxan or Araba, other forms of Plaquenil, other already off prednisone at the tir:re of the report, and forms of rheumartic disease therapies. At that point the dosages fi:r the other two had been reduced we used Entanercept. 4S PANIL DISCUSSION ACOUSTIC NEUROMA PANEL DISCUSSION II i,r,ith microsllrgely are as good as or superior to the resulis of radiotherapy" You don't have a lurnor Dr. Bradley Welling (Columbus, O}{): We askecl wiren you get done with mjcrosurgery. [With the: Dr. Thompsol to join tl're panel also. Samina knife] you still hal,e a tumor, and l'm sure Dr. ]ohn Flickinger is a radiation oncologisl and that will come up in the discussion. professor in the Deparlment of Radiation Oncology 1'he goal of acoustic tumor microsurgery is to and in Neurosurgery" He has published extensively completely remove the tumor. I'reservation of hear- on the use of the gamma knife on intracranial and ing is a sornewhat elusivr: goal but nevertheless a other tumors, including more than 250 articles in realistic one in lnany cases" Of rr:urse, the goal of peer-rcvier.ved journals and chapttrs. We apprcci- radiotherapy is not total tumor rernoval, and tirai ate him beirrg with us here $day. also will be discussed. Thjs is nothing new to any of Dr. Jens Thompsen from Copenhagen, the you here. l will briefly review the data hecause we Wiliiam House gr"rest of honor for the Amelican have presented lhese statistics before. Neurotology Societlr, l-ras also extensively pub- We use three approaches*middLe fossa, :etrosig- lished and h;ls a wealth of expurience in the treat- moid, anri translabyrinthine*for acoustic neuro- ment of acoustic tumors. mas. We use the tr:anslab,vrinthine approach in Dr. Derald Brackmarn needs no iutrtduclion" Fle ahout ha1{ o{ our cases. Any tumor that results jn is past presideni ol the Arnerican Otological Societv nonser:viceable hearing or any tnrnor that is more ard has rnore lhan 260 pr:blicatious and chapters to tharr 2il: cm \4/e treat with the translabyrinthirre ap- his credit. proach, feeling that hearing preservation would be Fina11y, lJr. Krvin McKennan is a neurolr>logisl rxtremely unlikeiy. who has been in practice in Sacramento for 14 years The resulis fnr the middle fossa approach were and has recently laken the gamma knife course and presented here last year" We have some measurahle gone through the rigors of bccomir"rg traincd to per- hearing preserrred in about 801, of cases. The hear- form gamma knile stereotactic radiation therapy as ing is serviceable, very audible in aboui 60% of weli as microsrirgical removaJ. cases, and the complication rate for the rniddle 1 will start by asking our panelists to spend 5 Iossa approach is extremely lolv. The mor:tality has minutes each introducing their area of expertise io been zero. r-rs. I would like to start with Dr. Brackmann, fol- The results in lrlll2 are the samo as in our unilat- lowed by Dr. Flickinger, and then Dr. Thompsen eral rases. We are wriiir:rg up these resnlis right and Dr. McKennan. nolt,. We have 4{J palients who have been treaied by Dr. Ilerald Brackmann: Tl"rank you vcry much, a n"ricldle fossa approaeh for small tumors and NF2, Bradley, and congratr-rlations, ]u1ia anr-1 Cary, for and the resr-r1ts are actually equivalent to what they running an on-titne meeting. are in unilateral tur:nors*in fact, they are slightly The most recent articlc on the gamma kniftl for better. acoustic tumors was an exceilent review' fronr the W* have preserved class A r:r B hearing in about University of Virgirria" it just came out i'rr this 60'X, o{ tirose paiients and some hearing in about mont.lr's Nettroxtrguy. il"he conciusic'rn was that mi- 65"1,. T'hose results, by the wayr art: superior to ther crosurgery remains the primary r:rodality for: the results achierred wiih tlre gamma knife or fraction- treatment of mcst acoustic tumors, brrt that sur- ated ste::eotactic radiotherapy" So, particularly in geons who can't achieve the high lerrel of exccllent NF2, tlrere is a real quesiion as to whether yotl reported results n ith microsurgery should consider shor.rld e:,er irraciiaie a patienl with NF2. the gamma knile al their: primary modality for the I prepared a taik lor ihe Lr:xcell Society. They treatment of ttrmors. I would like to lerverse that were kind enough to invite me, and l had a lot of opinion. 1 am going to present the neurosurgical, tinre gcing ther:e . On the right side fof the slicie] is a neuro-otologicai, and rnicrosurgical results and quotation from the Archiars ttf OtolartlttgclogLT ln the slatr: that il is the challenge of gamma knife users to 1930s w}rere they say that any treatment other than meet ti"urse results. Lrecause I think that the resulls x-rav |lrerapy for tonsils*well, anyway, you should 50 PANTL DISCUSSION never surgically rrlmove tonsils. They shoulcl orrly tients that they ma1, feel safer: if we put their lumor be treated with racliolherapy. That's r-:ne benign dis- inlo chemotherapy. We cut the tum 5l PANIL DISCUSSION tion suggests*l don't know how well you can see talk aberr"rt all the patients who are operated on, all these small numbers*that perhaps at least for the the risks ihat they go through, ard compare nll lirsi 3 years you are going lo have patienis holding ihose things with radiosrirgeryr most patients will nn to hearing with observation versus radiosur- decide that they n ould be better off with raciiosur- gery. but a{ter thal, there will most likely be a ben- gery. Thank you. efit in terms of hearing preserlration. Dr. jens Thompsen (Cr:penhagen, Denmark): I Number four, we just need :nore time to assess arn going to elaborate on riotne ol the issues I dis- the results of radiosurgery. Twenty-five years o{ cussed yesterdav. First, it was otlr opiniorr some experience in Sweden and 10 years of experience in years ag{r*and this fits very well with whai Derald lhe United States does not te11 you everything you Brackmann w;rs jusi saying*that you should oper- want to know" We would like to see 25-vear results ate on these paticnts to achieve these gcals. How- o{ using the 1ow doses published from all ol the ever, wt; have changed a bit becarise of onr experi- U.S. centers, bui maybe by ihen we will all be re- ence with the "walt and scan" group of patients. tired and the HMOs wilJ only 1et chiropraclors and Again, our study was a prcspective study that in- LPNs manage these tumors. volved 123 palienls. Six had cystic [disease.] and Nlumber thret, radiation can cause ne\&' tumors in nine were NF2 patienis. if wtl ornit the NF2 and the cleveloping 10*30 yearsi or malignanl degenera- rystic patients, tl're yearly growth rate was 2.4 mm, tion. Some of the best data on radicltherapy for an and it did not differ betrt,een the 3t)*50-year age entily like this come from studjes of radiotherapy, group and the 60*80-year age group. for pituitary adenoma" Thousands of patients have You cannot use patient agr: as a factor in deciding been treated in large serie; with fol1ow-up to 20*30 how and when lo treat the patient. Clearly, cystic years. Because of the 5-cm fields used for treating tumors grow very fast compared to other lumors, piluitary adenomas, the risk ol a neu, tumor devel- anci il you see a picture like this on MRl, it's advis- tping is a bit larger, about 1%*2% in large series. able that you r:perate on that patient as quickly as The new tumors are about evenly divided between passible, because ihese tumors have a great propen- benign and malignant. sity to grow. Here I show four pictures of a 78-year- We think the risk with single-fraction raciiosur- old man taken at 2-year intervals, and this is where gery to smaller fields lnay be higher by a factor of we made our mistake. We should have operated on 10. We are working wiih the lJniversity of Califor- the patient here, where the tumor has doubled in nia, San Francisco, and other cetlters tr.r try to get size" In this picture he is 80, this one was taken at more reliable figures, butt it will stil1 iake some age 82, and this was taken at age 84, rt hen he was timc to gct h,rrd dat.-r. bror-rght in and had to be operatod on aculely. So, Number two is a good one for scaring them age w111 rrot tell you anything. away: Didn't Samma rays turn mild-mannered Whai might tell yor-r something is symptom du- Bruce Banner intr: ihe lncredible Hulk in that awful ration. Those who have a very shnrt duration of TV show? We have la picture ofl Hulk saving, $ymptorns tend to har.e much faster growing Lu- "Hulk should have had translab," with the gainma mars. This also applies to elderly palients who knife zapping him. lf this doesn't scare them at av, come in with relatively acute symptoms" In fact, then I get to the last reason you can use. This is onc this is also supported by the experiments we have for ihe surgeons to use before the patieni geis to the done on nude mice. The tumors we implanted raclialion oncologisl: "l{ you don't get radiation, in the nude mice lhnt camc from patit'nts wlth you don't have to talk tr: any creepy radiation on- a $hort hisiory had a mr"rci"r higher growth rate than cologists." And u'hy do thry hide radiation therapy tu:nors fri;m patients wilh a longer duration of deparlments in hospital basements next to morglles symptoms. As I mr:ntioned yesterday, rve have if they are not creepy? designi:rted iive types of growth" One is type A, These are my iop ten reasons, but unfortunately, steady growth; B is no growth over time; C is I havrn't been able to convince any of the palients a silent period with no grou,th; D is shrinkage to let me sleep in. (wlrich is something we have to accept, and in large AII of us want our patient: to have ihe best treat- tumors this happens); and the E-type tumerr is ment" We'd like to offer them a treatmenl that growing in a different way. In our series, 74'k af achieves 100% tumor control with no complica- tumors exhibited growth over tirne arrd 26% exhib- tions, and u/e don't have such a trealment. We do ited no growth or shrinkage" Crowth was unrelated have stereoiaclic radiosurSery, and it is coming to age, sex, or inilial turrror size, bui it was relateci to closer and closer to reaching that goa1. 1{ you dis- tumor rarliological architecture, and these are the cuss the cc;mplications with your patienls honestly, cystic tumors. 52 PANIL NISCUSSION if we introduce duratii:n of symptoms, it is pos- Io force us not to operate on patents purposely. Of sible to derive a mathematical formr"rla that r,r,ill tell course, we wer:e not doing operations against tlre you whether or not a patient has a chance of having patient's wi1l, but that is the way they think. a growing tumor, but we have nol vet started fig- They want to postpone eve:ything, anel the prob- riring such probabilities. With regard to lrearing lern is, they are not explainil'rg to patienls whai preservatinn, "wait ancl scan" is not a good tactic might happen. Laler on, in talking to patients, we over time" If lr,.e use a 50/50 cutoff, 5211, lose their found that if you have a disease that aliou,s you to hearing in the cbseryation period, and at a 3A/7A waii almq:st forerrer, yor.r don't take it seriously" cutoff, about 70% lose hearing in the observation Then, once you operate, if anything happens it's the period*and this occurs evcn in patients with no tu- doctor's fault bec;ruse he shouid have recom* mor growth. Hearing; can decline independently of mended that you be treated earlier" Patients forgei whether the tumor grows or not. that they decide for themselves not to have the sur- In ihis study we followerl paiients until 1999; 85% gery. This is a facl of life in our countty, ancl we of the iumors exhibited grnwth, 89% of paticnts iost have to accept it" Today we ate not operating on eligibility for hearirg pr^eserrration, and 6'X, dir:d of any patient uniess ihe tumor is more than 2 cm in the tumor. F:orn ihese figures yorr could conclude diameter and we have two scans saying that this that we should have operated on these tumors a tumor is growing. Then, of coilrse, we have ti:1ook long time ago in order to improve these results. at our facial nerye results in 900 patients operaied However, you could also do a 180-degree turn and on. Until the tumor reaches abnut 2 cm, there is no look at things differently. For cxample, lq% o{ the great increase in {acia1 nerve problems. ll the pa- patients t'ho died, clied r,vith a tumor but not be- tient rt,ith a 10-mm tumor outside the meatus comes cause of the tumor. [4oreover, 42']/ )J PANEL DI$CUSSIOhJ impact on the treatment of acotrstic neuretmas in the: stick or-rr heads in the sarrd like ostriches and sir:nply lJniled States becanse Pittsburgh's r-rnit rvas the refusE: to accept the repeated pLrblished results of only one available. snccessful gamma knife treatmer:rt. Seconcl, we call i thought, and I recall colleagues commentins, refcr all of these pi:tenlial acoustic neurorla pa- tirat the unit il Pittsbr-rrgh \,/as sonlel,vhat of an tients to a n€urosurge*n lr''ho perfilrms Samma odditv, that it really didn't affect orrr practices. i kr:rife radiosrlrgerv. I think lhis is unnecessary and calmot recall a single patient irr my practice asking not in lhe Llesl inierest of patients. Wr: as ENT sr:r- about gamma knife treattnent prior tr: 1998. Idon,, georrs diagrroser the rrast majorilv of acousiic neuro- with the expansion of the inter:ret, I would say that mas. We harre ihe bcst understanding of the ar-rdi- probably 50"/n of my patients inquire about the tory, r,estibular, and facial nerrre$. Wt: are the best gamma krrife, whetller I brirrg it r"rp or not. There are traincd to treat tl"re compircations of cranial nerve now 112 gamma knjfe uniis throughout the urorld. lesir:ns. We harre the diagnostic and research capa- More than 50,1)00 patients have been treatei-I, anLondon" I submit- knife has a role to p1a;r in treating acoustic neuro- ted nry prr:posal lo our hospital's garnma knife mas. Wr: need to clefine that role. Elder:lv patients unit. I .llad the supplrrt of serrerai local neulosur- with small to medium-size lumors that are growing gllons, all of my HlrlT colleagues, and many other are probably ideal candidates for this t'eatmeni" physicians on the hospital staff. They may not necessarily neeci the long-term solu- Llrrfortunateiy the r:er-rrosr:rgical director of the tion affi:rded lry sr-rrgical excision. PaLients witlr re- urrit vigoror-rsly opposed my proposal. I know of current or residuai turnors, those wlth turnors in "ri'r similar opposition in virtually every other center in only hearing eal, and patients u,ho have rnedical tlre United States. At this time, all 42 gamnra knife contraindications to surgerv art certainly candi- centers in thc United Stat*s are co-directed by neu- cl,rie: li'r {Jmm(r krrilt' tre.rtrnt'rrt. rosurgeoil$. If our specialty does nol break this rno- On lhe other hanr1, the most ardent supporters of nopoly, we will lose the opportunity to de{i:re the ti:le gan:lma knife advise against its use in large tr-r- role of the gamma knife, not only in the treatment mors r,vith brain slerrr or crreirellar compressir:n. of acoustic nr:Lrromas but in the treatmenl of other The l:ng-term rr:le of gamrna knife treatment is t1n- lnmors of the skull base as well. In the end, our cerlain in pati*:ts with srnall to mEdii.rm-size tu- patients may suffer from this turf baltle. if the lnors, especially those with good hearing. Hither gamma knife proves lo be a successlul long-term neurotologists will help determine the role or oth- manasement tool, we, not the neurosurgeons/ *rs will cletelrmine it withorrt our inpnt or expertise" shorrld be using it. If the galrlma knife does not As I see it, we have three choices. First, wr: can provide succrssful 1or:rg-term managefilenl, that 54 PANET DISCUSSION aiso needs to be exposed. As for the proverlria1 fork bit better, but witi-r lhe newer results, we have in the road I pointed to earlierr, I think we have only found concem about trigeminal neuropathy. lf you one choice, and that is to get invr:lved with the treat these iurnols while ihey are stiil intracanalicu- gamma kni{e and define iis role. lar, then lhere sl-ror-lld be zero risk of developiag Dr. Welling: We have some diverse opinions on any facial numbness, and also the risk o{ hearing the panel; that's good. Could we have the next tray loss should be 1ess. We har.,e had no patient k:se of slides, please? Let's go t}rrough a coupk: of cases hearing with moderate lloses in intracanalicular tu- ;rncl gct the feeling;s of ihe pane1. mors. One patient dr:opped in hearing {:om grade .l The first case is of a 56-year-old retired nurse to grade 2, so I think thai such patients have abont who came in with a 6-month histor:y of right-sided an equal choice between observalion and radiosur- tinnitus and mild hearing loss. Her past medical gery. With the medical contraindications, mic:osur- history was rnost significant for insulin-dependent gery could be consjdered, but you would want to diabetes and a coronary artery bypass grafl 4 years think twice about that. previousiy. She was asymptomatic. She had Dr. Welling: Dr" Flickinger, there was a reporl searched the net. Sl":e came in with a note from her out of Seattle recently th;rt showed ihat intracana- cardiologist saying that it was okay if she had sur- licular h"rmors **"n i" be associated with a higher gery, although she was at increased risk" The physi- rate of facial nerve injurir at the time of radiation, ca1 examination w,as otherwise unremarkable. An although I think the dose used was around 18 Cy. ls audiogram showerd very mild high-frequency ioss it rr ore difficult to irradiate a small intracanalicular but essenlially nonnal discrimination, almost sym- turnor than one that has more mass to it, in the CP metric hearing, and a fairly small intracanalicular angle? tumor. Dr. Brackmann, how much role do you a1, Dr. Flickinger: I don'l think so. That may have 1ow vour patient in the choice of treatment, and been a function of the high doses used in early ra- :,vhat woulcl you reeommend to this patient? diosurgery. ln the ear:lv days of surgery planning, Dr. Brackmann: The treatment choice is aiways and particularly for the small tumors, they r,r,ere the patient's" You apprise them of the possibilities, probably treating volumes that were much larger, inc.luding radiotherapy, and then they make the de- so even lhough they quoted 1B Cy, that dose is the cision" Because of her special medicai problems, 1 minimum dose. The dose to the facial flerve may would recommend repeating her scan in 6 months actually have been higher than it is r,vith mociern and rloing nothing at ihis time to see if this is a planning. Now wc use lnwer doses lo begir:r with, growing tumor. I do that in almost all tumors ex- so that may turn out to be a dilferent problem. Bui cept the small tumor:s in patients with good hear- certainly with the low dosages ancl modern tech- ing, where there is a significant risk to patients' niques, we have found zero risk of facial neuropa- hearing if thev wait. If sher did not have medical thy. cr:ntraindications or relative contraindications, 1 Dr. l{elling: Does the panel have any treatmr:nt would recommend surgery right awiry but since recommendation for this patient either than wait she does have contraindications, I would follow her and watch? for the present. Ilr. Thompsen: I would obviclusly r,t,ait and Dr. Flickinger: I think the standard approach for walch in ihis patient, but I would also warn against somebody r,t ho is at medical dsk, and also the stan- doing MR1 toci often. ]f the average growth rate of dard approacl"r for a small tumor of this size, is these lumors is somewhere between 1 and 2 mm observalion. For years, that is what we always pre- lper year] and you obtain an MRI study after 6 sented. Even patients who really wanted radiosrrr- months, you rnay not be able to discern any dif{et- gery we for t1-re mosl part talked out of it for some- ence between the two images. We would wait at thing this small-particularly when we were starting least 1 year between imaging studies in order to out, when we thoughl the risk of hearing loss and control the tumor in this patient" facial weakness would be the sarne for a1l o{ these Dr. Welling: L)o Srsp fear missing ihe patient who tumors. With t1're newer results, and seeing how has a tumor growing at 2 cm per year if you don't many patienls have lost their hearing over tim*, I get that firsl 5-month scan? now iend to offer longer cbseirvaiit;n or radiosur- Dr. Thampsen: lt'Jol in lhis siiuation. if it was a gery as equal choices. I still iean toward obserrra- cystic tumor, then the situation would be different, tion. I feel better ls),chologically if I can fo1low pa- but in the soiid tumors, we are not seeing a 2-cr:r tients closely and pick up hearing loss when it is expansion. sti1l very sligirt, or at thc earliest sign of progres- I-et's go to our next casel. sion, and treat ihem at that poinl. I ihink it's a little Dr. Welling: This is a 39-year-oid man who un- 55 PANEL DISCUSSION derweni a suhoccipital excision of a right acnustic r,r,ou1d probablv be the clecision that he would neuroma at age 32 with profouncl sensorineur;rl make not to undrrgo operation. hearing loss and seyenth nerve loss of continuity" A Dr" Flickinger: it seems lhat a lot oi palients and primarv seventh nerve anastornosis was per* physicians think that if yi:u have tu''() differeni ap- formed. When he underwent follow-up MRi at 2 proaches to control a tumor, then, ii the first one and 4 years, there wa$ no evidence of recurrence" you iry fails, ytru can tly the other, su in that re- Now, however, at the 7-year follow-up, he does spect, radiosurfiery afier failed surgery seems logi- sholv sclme evidence of recurrence. His facial nerrre cal. Bul the tumor control rate for these recurrent is House grade 3 with moderate synkinesis. He tumors may be ion er with radiosurgery, perhaps does achieve full eye closure with effort. The au- dou,n around 90%," This man is a young patient, so dir:gram confirms a profound sensorineural hear- the tumor is certainly accessible lrv a translab ap- ing loss and suboccipilal exposrtre, profound hear- ploach. It's a small tumor, and we wnulci expect ing 1oss, and thtn a sma11 recurrent lumor after sub- good results with m.icr*surgery, but I would pre- occipital excision. Dr. Lirtlricum presented some sent that as thc first treatment option, and I would interesting data yesterdav about the influence of ihe certainlv Lre lvilling to do radiosurgerlr il the patient gangiia on possible recilfl'ence. Dr. Brackmann, ltrhat lcfused that. is the di{ference in recurtelrcc in youl practice in Dr. Thompsen: I ll,ould recommenrl translab re- terms of tumo:s that have been removed suhoccipi- moval Lrut Nrould not promise anything about the lally versus through a translabyrinthine approach? facial nerve" if rhe patient is adamantly against any Dr. Brackmann: I)rad, as you know, we don'l deteriorafion, then you must wait and see lrrhat harre a great suboccipital series. The ones that w'e happens, and then the next time, if the tumor is have seen have primarily been treated else-"vhere. bigger, he maSr say, Okay, Iei's take it out. About 32 patients harre now come to us after having Dr. Welling: The next case is o{ a 21.-year:-old undergure sr,rboccipital $urgery elsewhere with re- asymptomatic woman whose father has IJF2. Her current disease lhat we have removed by a translal: audiogram is normal, but she has a sma11 intracana- procedure. Usually the recurrence is here in the licular tnmor on the left and a 2"5-crn brachial suboccipiial approach. In our translab $erit:s rve plexus tumor. i{ere is her audiogram" Here is the have had srven lecurrences in over 4,000 case;, so it tumor. Whr: on tlre panel u,ould take this out sur* is extremely uncommon, anci al1 of the lesions have gically? Wl:ro would u,'ait and watch this tr-rmor? Is been very large lumors. Specifically in this case, radiation the primary treatment modaliq.? Brad, how was the facial uerve reconstruct*d? Dr. Brackmannr You knaw that ltJF2 trrmors will Dr. Welling: lt was by a primary anastomosis. grow*wh1, wait and watch? It's a given that they Dr. Brackmann: From where to where? are going to grow, so thal's ihe standard of care in Dr. Welling: lt was in the cerebellar pontint: this country: io diugnose lrlF2 or find asynptomatic angle loward the meatus, where jt was recon- p.rtients, and to screen siblings or chiklren an,"l then structed, I belierre. watch them. You uratch them until tl"re lesions are Dr. Welling: What would your lreatment options too big to save their htaring. You know she has a be? This fel1ow actually said that he would rather disease that will progress, so why u'ait? Your best dir: than go through facial rehabilitation ag.-rin. chance to save her hearing {or her lifetime is to take Dr. McKennan: ln a 39-year-i:ld patient who is that tumor out. already deaf in the ear, I would do a translab exci* Dr" I{elling: We went ahead and took this tumor sion. With modern monitr':ring techniques, I worild out. The paiient did lost h*r hearing; when we iook anlicripate being able to resect the tumor completely it out,. $he was very interested in a prophylactic and cure l:rim of tire problein. That wor"rld not be my vesiilrular nt:rve resection on the opposite side. recommendation if this fellow were 69 years *1d. Woulcl you consider that? That is a different story" 1n a 39-yzear-old I would Dr. Brackmann: l{/e'r,e considered it but we'r.e also have concerns about the lorg-term manage- never done it. ment over his exp*cted lifeiime, which might be 40 Dr. Mckenna: Dr. Brackmaill1, I lrrould rvail be- years more. fore operating on this patierrt. She is totally asymp- Dr. Brackmann: That ro,rould be my preference tomatic, and 1 have been impresserl urith the in- too" I would not expect the facial nerve lo be greatly credible variatir:n from patieni io patient with involved within lhe internal auditory cana1, and 1 liF2*everr within tire same patient. A patient can think you could preserve it. He rnay have alrcady have a 4-cm tumor on onc side and on the opposite made lhe decision, alihough if he said he would side a tiny tumor that rnay not grow for many, rather die than risk facial nerve weakness, that many years. 5o I don't think you are gaining 56 PAI\Tt DISCUSSION anylhins by operating on a patient who is totaliy or-rr patients to preserve hearing. We have obtained asymplomaiic wiih a small tumor on olre side. I EECs in all of our middle fossa cases before and think you can safelv wait in this case. after and several years after middle fossa surgery. Dr. Welling: Thank you. We could stay here the Over 90% cif these patients have EEC changes that rest of the mr:rning, and probably the rest of the are permanent, and on paper the figure looks seri- day, discussing interestillg cases and management. ous. They don't have any symptoms whatsoever, I thank our panrlists. One final short comment. but in a pilot study, it might create a problem" 5o Dr. Thompsen: I have a comment about the we are not that hoppy about middle fossa surgery. mirldle fossa, which is lrf course what Derald had in It could be that u/e are not good enough" mind when taking this tu:nor out. it sounds very Dr. Welling: There's room for furlher study on reasonable, but I am not sure that everybody can do this matter, and I hope we will have the continued that nrith the same success thai you have had. At support of the membership for prospective blinded least w'e have nr:t been that success{r,ri operating etn controlled studies. 57 TRANSACTIONS 2OOO / AMTRICAN OTOLOCICAL SOCIETY AN INTERACTIVE THRTE-DIMENSIONAL COMPUTIR MODEL OF THT TTMPORAL BONT Musnyttlci lnou11e, M.D., foseplr Rabr:rson, A,4-"D., Keuin Montgo"*u:ry, Ph"D., *nd Miclwel SteTthanides, M. D. ASSTRACT Hypothesis/Coal: Development oi a threc-dinrensional interactirre computer model of the temporal bone. Backgraund: Lear:ring temporal botre anatonry is an integral par1 o{ every otolaryngclogy residerrcy program. The standard curriculum requires temporal bone rlissections, operative experience, and examinalion oi histology" [ssential to a working underslanding of this complex anatomy is the ability to concep- tualize the temporal bone irr three dinrensions. Computer-generated models are ths newest addition to the teaching armamentarium. Recent advances in hio- imaging and cornputer technology have enabled the creation of an arralomi- cally accurate three-dimensional model of tlre temporal bone" Methods: Fiity serial histologic seclions of the lernporal bone were scanned into a silicon graphics irrdigo Elan conrputer. The images were then processed using RAVt {reconstructiorr and visualization environment) software, which was developed at this instituiion. Contours were drarvn around vatious struc- tures, including ossiclesr nervcs, vessels, ancl the cochleovestiL:ular systenr. These c.lntours were then registered and a three*dirnensional sur{ace mesh was crealed. RAVI visualizalion software was then usecl to produce a three- dimensional mode I of each structLrre. The featr-rres of this program irrclurJe tire ability to adcl or remove any objeci; to control proximity, rotalion, color, and transparency; to produce a cr-rtting plane; lo visualize sterecscopically; arrd to manipulate the model in virtual reality with real otologic instrr:ments which are tracked in space" Results: An interactive thrre-dimensional computer model of the lemporal hr:ne" Conclusions: Altl"rough iloiogic training n,ill contir-rue to be based iln lem- poral bone clissections and operative experience, advances in computer lech- nr:logy have allowed the creation af an innovative adjunct to the teaching arnramerrt;:rirr m. Reprint requests: Masayuki lno:"lye. M"D., Department Of Otolaryngology, Stanfi:rd University Hospital, 300 Pasteur Drive, Sta:rford, CA 94305; ph. 550-725-6500; fax {r50-725-5962. 58 TRANSACTIONS 2OOO / AMERICAN OTOLOGICAL SOCIETY HISTOPATHOLOCY OF RTSIDUAL AND RECURRINT CONDUCTIVE HEARINC LO55 FOLLOWI NC STAPIDECTOMY {oseyth B. l'[ndo/, Jr., M.D. ABSTRACT Hypothesis: Histr:pathc:logic analysis o{temporal bones from patients who in life had undergone stapedectomy may provide new information concerning the causes of bolh residual ancl recurrent conductive hearing loss {CHL). "10 Backgraund: Although closure of the air-bone gap to wilhin dB occurs in approximately 90% of primary stapeclectomies, a residual CHL occurs in ap- proximately 10o1, and recurrent CHL may occur in up to 35% of cases. Revision surgery has provided clinical infcrmation concerning putative causes of failure r-lf tlre primary surgery, including erosion of the incus, bony replrowth at the oval rvinclow, and displacement of the prosthesis. Most reporls on the histopatholr:gy r:f tenrporal bones from such patients have {ocused on complications of surgery, with little attempt to corrslate the postoperative air-bone gap with the observed histopathology. Methods: A retrospective review o{ our collection of tenrporal bones uncov- ered 22 cases with a postoperative CHL of 10 dB or grealer (air-bone gap averaged at 500, 1000, 2000, 3000, ancl 4000 Hz, using pr:staperative air and hone conduction levels) {ollowing slaperieclomy. These tenrporal bones were prepared by standard methods for light microscopy. Results: Of the 22 cases with postoperative CllL eqLral to or greater tlran l0 dlJ, there were 19 with residual CHL,2 witlr recurrent CHL, and 1 with botlr -[he residual and recurrent CllL. most common histopatlrologic correlaies oi residual and recurrent hearing loss included resorptive osteitis of the incus (64Y,,,), obliteration of the round window by otosclernsis (23%), the prosthesis lying on a residual footplate {ragment (23y;}, the proslhesis abutting the bony margin of the oval window (1 B%,), adhesiorrs in the r-licldle ear (i 4Yn), ;:nd new bone l'ornration ir"r the oval window t14"/n). The nrean postoperative CHL in those temporal bones w,iih round window obliteration (n = 5) or resorption r:f the incus (n ' 14) was 38 dB and 27 dB, respectively. Tlrose cases with three findings had a greater postoperative conductive hearing loss than those with r:ne finding. Conclusions: Histopathologic examination uf temporal bones fronr patients who in life had undergone stapedeclonry provides useful information coilcern- ing the causes of both resiclrial ancJ recurrent CHL" These data provide a hasis {or inrproving both surgical lechr:ique ancl prosthesis design. 59 TRANSACT:ONS 2OOO / AMIRICAN OTOLOCICAL SOCIITY Reprint requests:]oseph B. Nadol, Jr., M.D., Massachusetts Eye and Ear Infirmary,243 Charles Street, Boston, MA 02114-3096; ph. 6W-573-393s. E-mail: [email protected] 60 TRANSACTIONS 2OOO / AMIRICAN OTOLOCICAL SOCIITY HISTOLOCIC STLJDIES OF THE POSTIRIOR STAPEDIOVISTIBU LAR JOINT IN OTOSCLEROSIS Sauruil N. It*erclmnt, M.D., Armngnn Incesulu, M.D., Rabert l. Glynn, Sc.D., a.nd loseph $. Nud.ol,lr., Ivl.D. AESTRACT Objective: To deternrine the prevalence of ankylosis cr otosclerosis at the posterior stapediovestibular.ioinr {SVJ) irr temporal bones with oir:sclerosis, with special reference to stapes surgery. Sackground: The long-term success r::{ the laser STAMP procedure, anterior cruroiomy, and sirnilar partial stapedectomy procedures depends on lack of ankylosis and lack of otosclerosis involving the posterior SVJ. Previous work has shown that the air-L:one gap in otosclerosis correlales with narrowing and loss o{ the SVf space. However, the prevalence oi and histologic features of oto- sclerotic involvement of the posterior SVJ space have not been well character- ized. Methods: Histok:gic assessment of serial sections thrriugh the oval window niche in 140 temporal bones with otnsclerosis that had been sectioned in the axial plane {age range, 20*95 years, mean 3 68). Bones with siapes mobiliza* tion or stapedectomy were excluded. Results and Conclusionsr Two of 140 bones had otosclerosis exclusively at the posterior SVJ. Of the renraining 138 bernes, all of which had atosclerosis at the anterior SVJ, 82 bones also had otosclerosis atthe posterior joinr. Of the 56 bones without otosclerosis of the poslerior joint, three exhibited bony ankylosis of the posterior joint. Thus, 53 bones (38%) had neither ankylosis nor otoscle- rosis involvirrg the posterior joint, and would be potentially suitable for a laser STAMP or a similar procedure. There was no correlation between otosclerosis at the poslerior SVJ and age, $ex, or duralion of condr-rctive hearing loss. Otosclerosis at the posterior joint in one ear was significantly associated with its presence at the posterior je;int in the opposite ear (P = 0.0"1). The audiogranr cr:uld not be used to reliably predict otosclerotic involvement of the posterior SVJ or the degree of fr:otplate pathalo5iy such as ankylosis. Supported hy funding from the Silversiein Young lnvestigator Award, the Lynch Foundatir:n Research Indcwment, and NIH grant No. R29 DC003557" Reprint requesls: Saumii N. Merchant, M.D., Department of Otolaryngology, Massa- chusetts Eye and Ear ln{irmary,243 Charles Street, Boston, MA 02114-3096; ph. 617 -573-3503; fax 677 -573-3939. 61 TRANSACTTONS 2000 I AMTRTCAN OTOLOCICAL SOCITTY A COMPARISON OT TNC RESULTS WITH POSTUROCRAPHY FINDINCS FROM THT BALANCITRAK 5OO Mnnrili Arniu, l\,l.D., Itlnrisn Girnrdi, M.A., Horsf R" Konrnd, M.D., rmd Larry F. Hughes, Plt.D AESTRACT Objective: To clelermine a correlation betrveen conventional electronystag- mography (ENC) findings and results obtained ironr BalanceTrak 500 pasturog- raphy assessment. Study Design: lndividr-rals r,vitlr a variety of dizziness and baiarrce disorder symptoms wero testecl with both ENC (ocular moior sludies, positlonallpositioning testing, and caioric testing) and with comFluler posturog- ra6:rhy using the BalanceTrak 5001" Setting: 1-ertiary re{erral conter. Patients: Urban/rural Midwesterners referred for dizziness arrd balance dys- function symptoms. lntervention: Results of both testing modalities wertl sent to referring physi- cians. Outcome Measures: INC and posturography results. Results: When tNC results were compared with BalanceTrak findings, a rnajoriiy of lhose patients whose ENC findings indicated central and mixed etiologies, or peripheral lesions olher than BPPV, had abnormal iirrelings on posturography. Speci{ically, tests sinrilar to the [Jaiance Masler Sensory Orga- nization Tests (5OT) 4 and 5 arrd a newtest, Limits of Stahility (1()5), presented the most difficulty for these inriividuals. Patients with nr:rmal ENC iindings and those with BPPV harJ mixed results on posiLrrogra1::hy. Resuits fr:r specific individual ENC tests were compared with posturography findings. No correlatic;n was noted anrong any of the ENC results and posturog- raphy findings. Furthermore, there was no correlation belween posturography and dizziness etiology. Conclusion: For many patients with dizziness andlor balance dysfunctions, posiurography carr prc;vide additional inforrnatiorr to that obtained with ENC testing. This is especially apparent for inclividuals who present with these symp- toms but have normal or borderline normal ENC findings" Reprint requests: Marian Girardi, h,{.A., Division of Otolaryngok:gy, Southern Illinois Ur":iversily School of Medicine, Ir.O. Box .19662, Springfiekl, TL 62794-9662; ph. 217- 785-5144; {ax 217 -524-0253. E-mail: [email protected] 62 TRANSACTIONS 2OOO / AMERICAN OTOLOCICAL SOCIETY A VTSTIBULAR PHINOTYPI TOR WAARDTN B U RC'S SYN DROME? F. O. Bl.ack, M.D., F,A.C.S., S. C. Feszn€cker, R""hl", K. Allen, M.S., and Clnire Gianna, ph.D. ASSTRACT Objective: To investigate vestibular abnormalitiers in subjects with Waarden- burg's syndrome. Study Design: Retrospective record review" Setting: Tertiary referral neurotology clinic. Subjects: Twenty-two adult white sLrbjects with the clinical diagnosis of Waardenburg's syndrome (10 with type I and 12 with type ll). lnterventittns: {1) [villuation for Waardenburg's phenotype, (2) review oi histr:ry for vestibular and auditory symptoms, anc.l (3) tests of vestibular and auditory function. Main Outcome Measures: (1) Results of phenotyping, (2) results of vesiibular anrJ auditory symptom review (history), ar"rd {3) results of vestibr-rlar and auditory function testing. .17 Results: There were wonren and 5 men in the study. The age range was 21*58 years (nrean age,3B years). Sixteen of the 22 subjects presented with a chie{ complairrt of vertigo, dizziness, or imbalance. For subjects with vestibular conrplaints, vestibulo-ocular tests (calorics, vesiibular autorotation, and/or pseudorandonr rot; tion) were abnormal in 77'1, and vestibulospinal function tests (computed dynamic posturography, EquiTest) were abnormal in 57o/o, but there were no speciiic patterns oi abnormality. Six had objective sensorineural hearing loss. Thirteen had an elevated summatinfaction poiential (>0.40) on electrr:cochleagraphy. All subjects except those witl"r severe hearing loss in = .i; had nornral auditory hrain stem responses. Conclusion: Subjects with Waardenburg's syndronre may present with a pri- mary complaint oi vestibular symptoms without hearing loss. Electrocochleog- raphy and vestibular iunctir:n tests appear to be lhe most sensiiive measures o{ otologic abnornralities in ;:ersons with Waardenl-iurg's syndrome who present with vesti bu lar conrplai nts. Reprint requests: F. O. Black" M D., F.A.C.S., Department of Neurotology Research, Legacy Holladay Park Clinical Research and Techni;iogy Center, 1225 NE 2nd Av- er-rue, Suite 3$3, F.O. Box 3950, Portland, OR 97208-3950; ph. 503-513-5353; fax 503- 413-5348. E-mail: [email protected] o,1 DISCUS$ION DISCUSSION PTRIOD VIII: H tSTOPATHOLOCYI/ESTI B U LAR DTSORDTRSIANATOMY Papers 26-30 Dr. C" Gary Jackson (Nlashville, Tl'il): These pa- burg's syndrome. The presentation was sir:rilar to pers are now open for discussion. M6nilre's disease, $o 1,1/e used to treat thtx with Dr. Herbert Silverstein {sarasota, FL): I really diuretics" Do you maintain tht: same type of man- enioyed Dr. Merchani's beautiful paper. When I agement, or is there something different v,'iih tl"re first started doing this laser STAMP procedure 5 Waardenburg's synd:ome patients? y€ars ago I called Dr. Schuknecht and askeel irim Dr. F" O. Black (Portland, OR): Thank you for the i{ this rvould work, and he said if you pick tire right comment. Yes ihat's true, we lreated them exactly cases wilh minimal otoscierosis, it probably will as we do hydrops patients-colservatively" The work. That was ihe impetus to ask Joe Nadol to good news is that they usually respond better than look at the temporai bone to see what would hap- patients with M6nilre's disease to conservaiive pen. Over the past 5 years u,e haven't had to re-fix management" any patient. Right now we have 50 patients. ln Dr. Hdward Monsell {Detroit, Ml): I have a ques- about 30% of them, after a laser stamp procedure tion fcr Dr. Nadol. A paper frErm the Warren group you have a beauiiful bh"re foo$late, minimal oto- about 2 years ago srggeite.l an association Lretween sclerosis, and vou think you're going to have a chronic suppuratir.e otitis media and incus erosior-r great result. Then you touch the stapes, and it is following stapes surgery. I wondered if you saw still fixed. This fits the histologic picture that Dr. any evidence of that. Mercl-rant detailecl, in that about 30% of iheni have Dr. ]oseph B.It{adol (Boston, MA): I'm not surE } otosclerosis, and you can't actually see ihe posterior undersland the questiotr, but certair:rly tlre necrosis parl of the {ootplate when you're in surgery until oI the incus can occur in chronic otitis media" you ky to mobilize the stapes. So I'm very pleased, Dr. Monsell: Specificaily, following stapes sur- and 1 think this explains our results. If r,ve pick the gery, incus erosion seemed to be more prevalent in right cases, we can stiil give the patient good patients who had a history of chronic suppurative hearing. If you can't do a stamp procedure yt'ru otitis. just convert ii to a pistnn procedure at the same Dr. Nadol: We1l, in 19 cases, lhere were none like time. that. i think in all of these cases thete was no evi- Dr. Allan Rubin (Toledo, OH): When we were in dence of any otalogic disease other lhan otosclero- Omaha, we woulcl see patients with Waarden- sis and the surgery that ihey unrierlt ent" 64 INTRODUCTION OF NTW PRTSINENT: A. JULIANA CULYA, M.D. C. Canl l*ckson, Nf.D. The next order of husiness is the intrr:duction o{ skills portend a presidency of great vitality and oul new Fresident. I'm sure you all recognize by purpose" Wiihoul further ado, I would like to in- now that the *lection of Dr. Culya to the presidency troduce A. Juliana Cuiya as lhe next President o{ of the American Otoiogical Scciety is a historical the American Otological Society. event. This notwithstanding, her career and unique RIMARKS OT NIW PRTSIDINT A Juliann Culyn, M.D" Thank you very much. I am really looking for- sent you with lhis gold lapel pin and a certificate ward to it mysel{, but I lvr:uld be remiss if 1 did not which reads, "American Otologicai Society Inc", recognize my eminent pred*cessar, Cary ]ackson. presented to C. Cary Jackson, M.D", President, 2000, Throughoul your career you have consistently ciis- in appreciation and recognition ol his service to this tinguished yoursell by excellent performance, and I society." believe the American Otoiogical Society has indeed ldext year we will be in fabulous Paim Desert, benefited from your leadership*most r*cently and Califomia. I invile all of you to atlend and, more most reievantly {ram your service as President. To important, to participate in this meeting. Without commemorate yr:ur year as president, on behalf of {urther ado, } will call this 133rd Meeting af the the American Otological Society I would like io pre- American Otologicai Saciety to a close" Thank you. 65 TXTCUTIVE SISSIONS BUSINTSS MEETINC MINUTfS*May 13*14,2000 President C. Cary Jacksr:n called the Business meeting to order at 12:30 p"m" The minutes of the April 24*25, 1999, Annual Meeting of the American Otological Society, lnc., held at Marriott's Desert Sprirrgs Resnrt, Palm Desert, California, were approved. The following new men":Llers were inlroduced to the Society by their respective pr(]p()sers: Actirtc Mentbs.: Stephen P. Cass, M.D., ptoposed bv Eugene Myers, M.D., and secr:rrded by Malcolm D. Graham, M"D.; Saumii Irl. Merchant, It{.D., proposed by Joseph B. Nado1, Jr., M.D., and seconded by Michael I' N4cKenna, M.D.; Lorne S' Parnes, M.l)., proposed by Brian F. McCabe, M.D., and seconded bv l]nrce l. Cantz, N4.D.; Debara t,. Tucci, M.D., prtlposetl by Rcbcrt A. ]ahrscloerfer, X4"D., and seconded b1r; Paul R. Lambert, M'D. Corr eslton dirt g Mantb ers Vicente C. Diamante, M.D., proposed by ltobert A. Jahrsdoerfer, M.D., and secordetl by Mansfield !. W. $mith, M.D. (Dr. Diamantr was unabie to altend this meeting); Takeshi Kubo, M.i)., proposed by Richarci T' h4ivamoto, M^D., ar-rd seconded by 1. Cail Necly, N{.D.; Thomas 1].U. Wustron, M.D., proposed by Robert A. Jahrsdoerfer, M.D., and seconcled b), Dr:uglas L Mattox, M.D. A Nominating Comr:rittee c*mposed of Drs. loseph Iarmer (Chair"man), lohn McElveen, Clough Shelton, Rich- arcl Wiet, Derald Brackmann, antl alternate Dr'. Richard Miyamoto uras clecled 1o prepare the slate of nominees for AOS of{icers for 2000*2001. REPORT OF THI SECRTTARY.TRIASURTR Dr. l{orst R. Knrrrad pr:esented the fr:llolving items of W. Hugh Powers, h{.D. (Senior), and Cesar Fernandez, informatian: M.D. (Associate). The present Membership totals 274 and ir:cludes the Members requesting transier tr: Senie'rr status are Rob- indr-rction of nelv memhers on May 13, 2000, as follows: ert $/. Cantrcll, lv{.D., Michael M. Paparella, M.D., and Mansfield F. W. Smith, M.D. 125- Active l0 l{onorarv l(equesting transfer to Emet:itus status is B. 1"{ill Brition, 72 Senior 7 Emeritus M,D. 43 Associate 16 Ci;rresponding INCOME AND EXPEN$E STATEMENTS The AOS Membership I)eveiopment Committee con- The following lncome and Expense statementr r,rrere tinuers to seek ont qualifi.ed canelidates lr,ho would be presented to the member:ship. worthy of prrtpnsal {or mcmbership irr lhe Society. Dr' AMEI(ICA}J OTOIOGICAL SOC]LTY, ]NC. Konrad encouraged the menrbtrship io continue to pro- INCOA4E STATEMENT pose qualified candidates for membership in the Society. lulr11, 19!)9, to April 3A,2004 The society is particularly interested in proposing candi- Begirrnir-rg Balance (Ju1v 1,199S).. "$ 89,321.32 dates for: ACTIVI: menrbership. Membuship Dues. . .52,200.00 Merlbers deceased since the last Atr:rual Meeting are Transactions Income . . . .2,405.00 66 EXECUTIVE SESSIONS ResearchFund...... 18,532.00 Brackmann, M.D. The Presidential Citation rvas pre- Interest & Dividends ..4,084.90 sented to Mr:. William ll. Williarrrs l{1. Ccrtificaieof Deposits ...... 75,000.00 MIN {""}TES-May 14, 2000 cosM ...... 17,125.00 Presicient C. Cary Jacksorr called the Business A.lo...... "...7,500.00 meeting to order at 7:00 a.m. Total lncorre ....$1 76,846.90 AMrfi tc,AN Or0t()c/al t $ociETv, rNC. REPORTS OT COMMITTHES Board o{ Trustees of AOS Research Fund: Dr:. } iorst R. txlt"\ 5t 5r,4n.-\4t.-\ 1 Konrad presented to lhe membership fhe Research lund Itth/ 1, 1999, to April 3A, 2AA0 Ctrtifi.ratcs of L)tpLtsit {4 @$25,{)AA) ...... $10A,AA0.A0 Reporl in Dr. l)ouglas Mattox's absence. The r,*lue of the llesearch Fund as of May 15, 1980, rvas $1,900,000. L)uring AC,.,tUttl ittl f,,,.r . . . 7,600.00 Annual Mertittg .....1,695.50 the 20-year period to March 24, 200A, the val*e oi tht: Midruiuter Cauncil lktting .12,058.22 Rescarch Fund inreased to $10,535,007.00. Th* total ex- Oflice txltcnses. "...... ,.3,092.16 penses to ihe fund for 1999*2000 were $4s2,608. This AOS Sccrrtf.tyial Stiyeud .....5,250.0A amount reflects the aclministrative fees in the amount of ACCME (Dut:s & RraL:crcditntit:ls)..." ... "..5,050.00 $1 15,525 and grants totalirrg 9377,'14E. The budget for l.rLternnl Rt'ztt rtut:Struitc .....9,3(.)0.AA 2000-200i is 258,711.00. The amount reflects administra- lrlY Siale Deyf . oJ Lazu .25A.0{) live lees ir-r the amount of $148,000 and grants totaling lnsurauce (llir" & Off", AO\/RcsFund) ...... 5,2il.A0 $110,711. The increase in aclministrative fees r*presents O t l.Ln' L tp r t tl i tu r es - S ub s u iyt t io n s, T r tw s o c t i trns, a.{fi c t an incr*ase in the investment advisor's fees. New, initia- Xcnt, Atottstital Socittr1 Mamberskiy, Misc.). .i6,4 15.97 tives for the AOS Research Fund include an AOS Scholars Total Disburscmeuts s / B.l,9al. s.; Crant to slrpport young inverstigators with a nrinimum of ,4MERrCl N OrOrOCIC,4t SOClrTv, ltfc. 50'/o time rommitmext. It prorrides sirlary support in the FININC'Ii, ST'4T]:M'NT arllount of $70,000.00 ;rnd research supplies ilr the lultl1,1999, ta A7u'il 30,2il0A amount of $10,000. lfhrl first applications wiil be accepted BaLance tm llsnrl 1ulV 1,19991 . . . . .89,321,3) ]an:-rary 31, 2001. The Research Fund reviewed and rec- Dcposiis: {nrcme. . .175,816.90 ommi:ndcd for funding by AAO-HNS COitE grant com- Total .. ..$266.168.22 mittec a Rr:sident I{esearch Award in the amount of Disburse weuts . .1 85,992.85 $15,000 per year. At tlre Tri-istees meeting on April 1, Bolnnce in Chcrkin;4 (4/3{)/{}A). . . .84,175.37 2000, eight grant$ wcre received and rerriewed. The total CertificotcofDcposit ...... 25,0A0.A0 ilmount of the requests was $291,925. Tr'r,o glants we::e llalnnt:e on. Ilnnd (April 30, 2A0A) . 3A5,175.37 lunded (one ner,r, and one re1"re1r,a1)" The total cost of the EIITOR-LIBRARIAI{ I{EPOI{T Dr. Juliarrna lunded grants u/as $110,71 1. Culya reported that Lippincott*Wiiliams & Wjlkins American Board of Otolaryngology: Dr. lulia Gulya would bo publishing ther 1999 Transactions. The reported on thc actir.itiers of the []oard. The Board contin- price remains stable. T|e ;rrchives are arissing the lies to admi.nister a two-part examination. 'llrree hundred volrrmcs ii:r the years 1882, 1919-7924, i'rnd 1928. We thirtv-four (334) candidates took the writtern r:xamination are still in scarch of these ndssins volumes to com- in Octr:rirer i999. Of those individuais, 307 became candi- plett ilre collection houscd at the ,Adams Center" Dr. dat*s for the oral examination. One hr"rndred tlr,enty in- Culya thanked th* mrmbership for allor,r,ir"rS hcr to dividuals, including ABOto Directors, $enior Exanrint'rs, servc as Ecliior-Librarian of ihe "American Otolagical and Cuest Examiners, on April 9*10,2000, conducted the Socir:ty. oral examir"ralion. Three |rundred for:ty-six (346) candi- Mer-nbers were reminded to pick up their numbers dates lor orai boards N,ere exantined. Three hundred for 1l-re annual phoiogr:aph, which was taken imme- twenty:one passed the exarrination and became certified. diately following the after:noon program. Dr. Michael E. Johns r ras elected President of the ABOto, PR.OGRAM A}V]SOTiY COM]VIITTEE to serve a h{o-year term. The 2000 wrliten examination Dr. Jackson thanked the {o}lowing individuals for: will be conducted on h.'lontlay, Septerxber 18,2000, in five sen ing on the 2000 Program Advisory Comnrittee: cities. The oral examinatio:r r,r,ill be conducted in Chicag<: 1)r:s. l. Owern Black, I{ichard Clrole, [3ruce J. on .April 2{}-21 , 2001. Cantz, L. Cale Gardner, llerman A. Jenkins, Paul R. Dr. Michael E. -lohns r,r,as elected Pre*ident rlf lhe AIlOtr:, Kiieny, john P. Leor"retti, Srenda l-orrsbury-N{artir:r, to serve a two-year term. Dr. David E. Schuller r,vas elected John K. Niparko, Dr:nnjs $. Por, and Clough Shel- President-E1ect, also for a tno-yeal' term. Dr. CeraLd B. ton. Healy was re-elected to a second term as Executive Vice- TJRESIDENT'S I{EMARKS, INT&ODUCTICIN llresiileni. Dr. H. Sryan Neel III conti*ues in his terrn o{ OF CUE$T OF HONOR, PRESIDE}JTIAL CITA- seryicc as Treasurcr. Drs. Jerorne C. Coldstein, Alexander TION, May 13,2000 ]. Schleuning, and Neil 0. Ward lvere elevaled to Senior The Business Meeting was adjourned and the {ilst Counselols. L)rs. lljchard A. Chole,.lack L. Gluckman, and $cientific Session started at 1:00 p"m" r,r,ith very brie{ .|csus I. Medina were clected to the Soard of Directors, rcmarks from President C" Gary Jackson. Tl:re Presi- Arnerican Academy of Otolaryngology: Dr. C. Rich- cleai inirodr-rced the Guest oi ]lonor. Derald E. ard l-{o1t, Executive Vice-Prcsident of thrl Amcrican 67 TRANSACTTONS 2000 / AMIR|CAN OTOLOCTCAL SOCrITY Academy of Otolaryngoiogy-l-lead and Neck $urgery, The Correci Code systern, produred by McKesson reported on the actir.ities of the Acaclemy. Cove{nment HBOC and used by a nr-rmber: ol payers, has been shown and Legjsiativer{f irs: Ihe lnfant Hearing and Screcning by lhe Academy to be {aultv, especially with lespect to Act r'vas passed. It was universally adopted across the bmdling surgical pro{edurc$ togethrr that make no country. The patients'rights bi1i, which l"ras been strongly $ense and Lrased on inaccurale principles. Reimburse- supported by the Acarlerly, is now ir conference com- ment fi:r cnr{es that require the use o{ the operating mi- mittee., wlerc the Liisjurctior-r betrtreen House antl Sonate cr.rscope has br:er'.r r.rry problelnalic. espccially with conr- will be worked out. This legislation would allow physi- birred procedures r.vith nt:rrosur"geons. The Academy is cian$, not managed care personnel, to make medical de- currently working on clarifving those otologic codes that cisions, hold health plal"rs accountahle when they m.rke require the use of the micr:oscope tl'rrough the CPIIRUC bad decisions not in the patient's best interest; initiate a committee. timely and independent appeals process for patients; and T1-r* Acat-1em1. is vcry clerse to lalqching a new lnltrnet mandate adequate access to physicians, including spe- portal {or otolarvngokrgv-ENTlink. }iNTLink will pro- cialistr. Prompt .Payments Acts of 2000: A number of vide full-service capabilitv for the practitioner, both states have successfully passed this legislation. The lSoard community and academic, and lrill iink seamiessly to of Covernors and the grassroots legislaiive netr,l,ork con- the Acad*my and Foundation. ENT{-ink partnerillg tinue to u.,ork hard for nation;rl passase. Practice Affalrs: with another company for practiiioners r,vi11 be an *x- The RUC and IEAC commitiees continue to t,ork hard ti:r pense. l)iffereni amounts haye been suggested, Lrut updatc CPT codes and to ider-riify those that are urder- it will probablv cost less than $1,000 a yerar to set up a valued. The Academv plans to conrluct a reimbursement web site with accrss to patieirt ci:des. A demonstration and coding meeting for representatir,es from altr sr:cieties web site will be up at COSM this year. Y*ry soon tl-re to plan l-row otr:iaryngology can r,r.r:rk tor,r,ard timely ar"rd popular Antimioobial Pi:cket Gqide, by Dr. David cor"nplete respon$e to HCFA and other agencies r-rn cod- Fairbanks, wlll be available fo:: dolr,nloading to a Palm ing .rnd reimbur:er)r('rrt ir*trr':, filot. REPONT OF THT AMTRICAN COLITCE OT SURGTONS Dr. llicharcl Wiet, American College ol Su::geons Gr:v- 2000, r,r,ith a focus on cervica.l paragangliomas and. vugai ernor rapresenting the Amerjcan C)tologiral Society, up: tumors. elated the membership on the aclivities oi ihe Amcrican RETORT OF THE AWAI(D OF MERIT COMMTTTET College of Surgeons. The College has 62,000 members IJr. Charles M" Luetje, Chairman, reported thal he had and assets totaling $245 miilion. The College was formed conferred with his committee rnemhers, Drs. C. Gary in 1919; currently 3,972 members are otolaryngr:logists. Jackson, Cregory J. Matz, F. Or,ven Black, and Paul Lam- The College has receivecl a report that the Council of bert, lor the selection of the 2000 Award of Merit rccipi- N{edical Specialty Societies (CMSS), rvith the American ent. Dr. Robert A. ]ahrsdoerfer was thc recipient r:{ the Board of Meclical Spccialties (AB\'{S), has met to cr:nsider award at the L:anquet heid on Sunday evening, May 14, an umbreila organization responsilrle for overseeing thc 2000. rlevelopment rf physician as$es$ment. RETORT OF THE AUDIT COMMITTTT The Eoard of Covernors has rec*mmended revision of Dr. Donald B. Kamerer, Chairman, reported on hehali th* Cr"ridelines for Optimal Ambulatory Surgery and Of- of hirnseii and l'ris col?mittee members, IJrs. Cordon B. fice-Based Surgerv. The Boarcl ;l.lso recommer-rded tl'rat a }-lughes and jolrn R. E. Ilickins. The committee reviewed stateolent on Physicians as lxpert Witnesses be distrib- the transnctions o{ the srrciety and fr:ur-rcl .-r.I.1 of the tran.s- uted to American College of Surger:ns lellows for usc in actions to be appropriate, nnd the consolidater-l balance trial settings. sl"reet o{ the American Otological Society to be in order. The College has initiateci ten ACS research {ellowships The committee recomm{:ndecl that the Council afir1 th$ for the year: 2000-2001 . The felLowships are proyidod to membership accept tl"ris report as indication ihat the fi- assist yolrng surgeons in erstablishing research prog.ams. nancial status of the American Otological Society, lnc., is The award is $35,000 per ycar for two years. excellent and being maintainer:l appropriately. A repolt of the C.ouncil of Advisory Chairs disclosecl ]IEPORT OT THE NOMIT'IATING COMMITTI]E Dr. William House's name has been subr:ritied in consid- Dr. ]oseph C. Farmer, Chairman, presented tire follortr* er:alion lor the Jacobson's Award lar Dr. House's contri- ing nominations for ihe slat* of r:fficers for 2000-2001 bution to acoustic neuroma surgery and cochiear lmplant year: fresident-Dr. A. Julianna Culva; Prerident-Elect* $urgery. Dr. Richard A. Chi:le; Secretary-Treasurer-Dr" Horst R" The next c$ur$e in Ctoiaryngology r,r,ill be at the Clini- Konr:ad; Editcr-l,ibr;,rrii:n-Dr. Sam E. Kinney; anrl Cotrr"r- cal Congress, to be held in Chicago on Oclobt.r 22 27, cii Members*Drs. Gregory J. Matz, C. Cary Jackson, Jcl- 68 TXTCUTIYT STSSIONS frev P. Harris, and John K. I(iparko. There r,r,ere no nomi- ADJOURNMENT nations fi'om the floor. l'he nominated slate was elected The Business Meetirrg r,vas adjor"rrned at 7:30 a.m. The by the rrlembership. Scientific Program cnntinued until 12:00 noon. 'fhe Award of Merit Committce for the year 2001 will be: Drs. Cregory J. Matz (Chair'man), A. Julianna Gulya, Respectfully submitted, C. Gary Jacksix. Richard T. Miyamoto, and George W. Horsl R. Konrad, M.D. Facer. Secre tarlrT'rmsu.rer 59 Cesar Fernandez, May 20, 191 0*December 15, 1999 Associate 1 973 A Full Life Cdsar Ferndndez was born irr Lautaro, a small town near T€uueo, Chile. As he r,vas grolrring r:p, he was interested in the arts and wanted to be a sculptor, but he acceded to his father's wjshes and became a mcdical dcrctor. He attended t.he Instituto de San Jose in T'emuco for premedical str-rdies from the age of l4 arrd rece ived his medicai degree frorn the Universjdad de Chile in Santiago" l{e thcn in- lerned ir"r the Hospital del Salr,ador and spent L2 vears as a physician there. ln 192tr1, C6sar co- for-rncled REoisia Ctorrhinokulr,gologis, r,r,hich has been published without inlerrr:ption up to tht: pre- senl day (volume 60) as the joLrrnal of the Chilean Society of Otr:laryngo1op,. He wrole tl-re first article in lhe jourrral. in 1948, he received a Kellogg Fouu- dation Feilowship Crart for advanccd training" He chose to take tlris training in the physiology oi hear- ing at the Centr:al Institutc for the Deaf (ClD) in St. Louis afler yisits to both Yale Medieal School and ClD" ln coming io CID, ht was foikrwir"rg in the footsteps of his compatriot, i. Saniiago Riesco- MacClnre, a coitreague from Hospital de1 Salva,-1or. While in Sit. l,ouis, C6sar tliviiled his time 1:e- lween Hallowell ]Javis's physiology laboratory at CiD and Walier Covell's histology lab*ratory in the C6sar Ferrr;indez Department of Otalaryngology at Washington Urri- versity. His mcst impr:rtant stuclies during this lime were his collaborations with lchiji Tasaki ancl Hal- the research staff at the Llniversity of Chicago, lowel1 Davis, and lrjs study of lhe innenration of where he remained for tlre rest of his career. guinea pig cochlea" With this experience, l-re devcl- Arourrd this tine, C6sar met his futr-rre wife, l]liza- oped slr:lrng interests in both str:r-rcture arrd function beilr Schroeder. They married ancl had a dar-lghter, that rvere to remain with him ihroughout his 1ife. Eva. Hallorvell Davis became a lifelong ir"rspiration to Cdsar collaborated with several of his colleagucs, C6sar. ln the small room in which C6sar did his inclr"rdirrg Henry ?erlman and ]ohn Lindsay. He microscopy, he l-rirng two pictures: one r:f Santiago and &obert Kimur:a worked on the cffects of lencrus Ram6n y Cajal arrd the other ol ]-{alkm,e1l Davis. obstructlon of the stria vascularis. He introcluced The terms of C€sar's {elkrwship reqr-ri::ed hirn to several of his residents to rest:arch, including return lo Latin America upon its completion even Ceorge Al1en, Paul Ward, John Fredricksrn, and though he w;rs sure that tlre best opportunities for Robert Kohul, who went *n to Lrecon:e leaders in the research he desir:ed were ir the United States. academic otnlaryngolosy. In his work in the co- Fror"n 1952 to 195:1, he conducted otolaryrrgology clrlea. Cisar was.ioined L:y Bob Butier, Toruzo Ko- research at the jnstituto de Cardlolojia, in Mexico nishi, and two talented postdoctaral trainees, Brian City. ln 1954, ]ohn Lindsay, head *f ololaryngology Johnstone and Vicente Honrubia. Het received a se- in thl Dcpartmenl of Surgery, inr.ited C6sar to jom ries of promotions with appointments in both the 70 IN MEMORIAM Divisior"r ol Otolaryngologl, and Department of was an inspiration for all who came under his in* Physiology, where he rose to professor, eventuallv fluence. became professor emeritus in 1975, and remained C6sar's interest in tl"re arts never waned. He had active in research for another quarier century" a Chicago Symphony Orchestra subscription with l{is longtime collaboration with Jay Coldberg be- his daughter llva and loved to visit the Art Institr-rte gan about 1968. C6sar had published over 50 papers in downtown Chicago. He was also an avid reader before he met ]ay, and published over 50 more dur- and especially enjoyed the poetry of Chile's Nobel ing the corrse of their collaboration. Many of the Prize-winning poet, Pablo Nloruda. latier: studies are considered landmarks in vestibu- C€sar will L"re greatly missed. lar physiology. For his contributions, C6sar was awarded the Cold Medal of the Bdrdny Society in 1978. He also loved teaching and excelled at it. He trained over 30 students, residents, and postdoc- toral fellows wiro are now heads of otolaryngology clepartments and significant researchers around the This memorial is reprinted with permis- counlry. Cdsar was a font of knowledge, which he sion of the Department of Otolaryn- gladly si-rared. His love of research and knowledge gology, the University of Chicago. 71 IN MEMORIAM W" Hugh Powers, M.D. Hugh fowers, M.l)" was an otokrgisl interested in the allergic aspects o{ ctologic disr:ase. FIe pr:ac- ticed most of his careor as part of the Otoiogic Medical Croup in l,os Angeles, and sr-rbsequently as a member of the Los Angeles Har Medical Croup. 'l\, % Dr. Porters was bortr in Dlrersville, lolr,a, and frB attended Boone High Scl-rool and Boone .|unior: Col- lege in Boone, Iowa" He graduated from Creighton Universitv in Omaha, IrJcbraska, and Creightorr qx University Medical School. Dr. ?owers served his interrship at \4ercy Hos- pital in Chicago, lilinois, and l-ris residency at the University of lllinols at Chicagc. He tiren obtainecl a Fellowship in Otology/l{eurotologv w,ith the Otologic Medlcal Croup in Los Angeles in 1964* IJr" Powers published numerou"$ papers, most of 1965. He remained as a membcr of the Otobgic which were rclatod to allerg,v.- and ihe aflects on the Meriical Croup with a primarv interest in allergics inner ear. He rvas * rnember oi nurnerous nalional a{fecting the ear until 1975, at lr,hich time he ioined medical societies, including the "friological Society the nervly developed l,os Angeies Ear: Medical and the American Academy of Heacl ;'rnd Neck Sur* Croup, r,r,here he pracliced r-rniil lris retirement. gery. He was \rery active in the Americ;rn Academy of Otnlaryngologic A11ergy, serving as its president frorn 1976 to1977. The'inforrnatirrr in this ohiiuary was obl.ri:red throirgh ther kirrrl- ness of Dr. i-,ucy Shiir of Arcpdia. Calilolria, 1,ho lv3s i1 p;ac. Dr. Poi,r,ers was predeceased by his wife, ]acqrre- ticc in Califon'ri.r rvith Dr. lo*,ers at lirc tinre i:f his retironrcnl. line. ]-{e had two children, Ma::k anti }anice. 72 NTW MEMBERS ?OOO NIW MEMBHRS 2OOO Actiue Members Stcphen ( .rsr Loren Parnes {phato not available) Debara Tucci Saurril N. Merchant 73 (.o r re spo n rl i n g, Ment be rs l'% 'l\, tu} 3 ax lph ol ct n at av a i I ab l e} Vincente Diamante Thonras P.A. Wustrou., Tal 74 TRANSACTIONS 2OOO / AMERICAN OTOLOGICAL SOCIETY 2000-200"1 MIMBIRSHtP LIST AMERICAN OTOLOCICAL SOCIETY, INC. Actiat Meurbers 1985 Dobie, I{obr:rt A., l{lHll\lLlCD,EPS; MSC * 7i80, 1987 Adkilrs, tr{arrr:n Y., 1187 Farm Qr-ri:rter ikl. Mt. 6210 Executive Blr,ri, Ste 400C, ljethesda, hlD 20892- l'lr',r-,tttl, SC 2(),1n4 71 B0 19B2 Alberti, F.W., 107 Clerrranti Roacl, Ker-rt Vale, Bk;ck 1988 lluckert, Lalry C., Dept. o{ Oiolaryngology, IrO l}ox F, #13*03, Singapore 12979A 357923, Seattle, WA 981S5 .1501 t987 Althaus. Sean R.,5201 NJorris Calyon Rd. #230, San 1995 Eby, Thomas L., 5th Ave. S. Birmingham, AI- Ramon, CA 9,1583-3405 35233 1995 Amedee, I{onalcl G., 1430 T'ulanr: Ave., 1\ert, Or- 1990 Emmett, Iohl R., 6133 Poplar Pikc at Ridge'way, le;rns, LA 7lll.12 Memphis, TN 38119 '1lay1or 1985 Applebaum, Edwarcl, 1855 W. 51., Chicago, 199.{ Facer, C}eorge W.,3643 }{idden Cove N.E. Roches- It. 60612 ter, MI{ 55906 1993 Babin, Richard W., 1830 Hwv, 51 So., Cor,ingtr:n, 1984 Farm*r, loseph C., Duke University Medical Ctr. TN 38019 Box 3805, Durham, NC 27710 1991 i3alkany, Thomas J., P0 8ox 0i6960-D48, Miarl-ri, Fl, 1990 r-.arr:ior, Jay 8., 5ll9 Bay St", Tampa, FL, 33606 33101 1978 Fredr:ickson, Johrr l\4., 517 S. Euclid, Box BLt5, 5t. 1997 Barrs, David M., 3404 Wake Foltst I{d., Ste. 303, I",ouis, MO 631 10 Raleigh, NC 27609 1987 Cantz, llruce 1., 200 Hawkins Dr", Iowa Cit),, lA 1992 Bartels, Loren J., ,l Calumbia t)r., $te. 510, Tampa, ;1),11 FL 33606 1983 Cardrrcr lr., L. Gale, i750 Madison Ave., Ste. 280, 1995 Beatty, Cirarles W", 200 First St. $W Rr:chester, MN Memphis, TN 38104 55905 1987 Cates, Ceorge A., Dept. of OtolaryrlSologv, P0 Box PO Box 1983 Biack, F. Owcn, 12?5 l\E 2trd Ar.e {97232), 280111, Scattle, WA 98195 1950, I:)ortland, Oit 97208-3950 1995 Coebel, ]oel A., 517 $. Euclicl Ave., Box 8115, St. 1996 Blaklev, Brian, Itm Cl] 421*820 Sherbrook St., Wln- Louis. MO 63110 nipeg, Manitoba, Canada R3.A 1R9 1989 Colderrrberg, Ilobert A., 111 W. First St" Ste 60{1, 1977 Sluestone, Charles D., 3705 Fifth Ave., Pittsbur:gh, l).rr lr'rr. OH 4ri4(l_r PA 152r3 1990 Goode, Richard L., 300 Pasteur Dr:. Rt35, $tanford, 1979 Brackrrann, Derald I:.,2100 W.'fhird St., lst Floor, cA 94305 l-os Angelers, CA 90057 1992 Covcoolea, L4arcos V., Pedro Lira 11154, 1988 Brookhor-rser, Patrick, 555 N. 30th $t", Onaha, NE l-lrquieta Lo Bamtchea, 68131 Sar.rliago, CH1LE Craham, Malcolm D.,,1700 Waters Avt., llox 23665, 1991 Canalis, Rin;rldo, 457*15th St., Santa h4onica, CA "l979 Sar.arrn;rh, CIA 31404 90402 1991 Cr-r1ya, A. l55B N. Cr:lonial Ter:race, Ar- 2000 Cass, Stephen Ir., 4200 E. 9th Avt. B 205; Denrrcr, Juliar"rna, lington, VA 22209 co 80252 1997 1984 Choie, Ricl.rard A., 660 S. Errclid, Box 81 15, Si. Louis, l-laberkamp, Thomas 1., 6726 N. Wildrn,,ood Ave., MO 63110 Chicago, tL 60646 1976 Clemis, lack D", 734 LaVergne Avt., Wilmettt, IL 1987 Harker, Lee A., 555 N. 30th St., Omaha, NIE 68131 60091 1987 Harner, Str:pl'rerr C., 200 Fir:st St., S.W., llochester, t985 Cohen, l.Joel L", 530 First Ave., Ngn, York, l{Y It}016 MN 55905 19BE Harris, P., 200 W. Arboi: Dr. 8895, San Diego, 1991 Cloker, Nervton "1., 6550 Fannin Sr.. Ste. 1727 , Hous- Jeffrev ron, TX 7703(l cA e2103 .1 1995 Daspir, C. l',hi1lip, 222 W. Thorras ltd., Ste. 14, 1992 Hart, Cecil W.[., 1053 f;ast E1 Alameda, Palm Phoenix, AZ 85013 Springs, C.A 92262-5815 1975 Daval, Vijay S., 3841 S. Marytrand Ave., Chicago, IL .1996 Hirsch, Barry 8., 200 Lothrop St., -$te. 500, llitts- 60637 bulgh, IA 15213 1991 De la Cruz, Arrtonio, 2100 lry. Third St. 1st Fl, I".os lL)92 HoIfman, Ronalcl A., 10 Union Sq E lrnt 2, New Angeles, CA 90057 York. NY 10003 1991 Dickins, John R.E., 1t1201 Kanis ltd., Liitle Rock, AR 1984 House, ]ohn W.,2i00 W. Third St., Los Angeles, CA 77.205 s0057 TRANSACTIONS 2OOO / AMTRICAN OTOTOCICAT SOCIETY L-987 Hughes, Cordon 8., 9500 ELrclici Ave. A-71, Cleve- 1981 Meyerhof{, William l-.,5323 }larry Hines Blvd, Dai- land, OH,t4195 1as, TX 75235-9035 1992 Jackler, Rcbert K., 400 Parn;lssus Ave. A-730, San 1987 Miyan:roto, Richard T., 702 Barnhill Dr., Ste. 0860, Francisco, CA 941143 Indianapolis, ,hJ.16202 1994 Jacksorr, Carol A., 361 llospital Rd., Stc. 325, Nlew- 1999 \4oretz, tr\rilliam H., 818 St. Sebastjan Way, Ste. 204, port Beach, CA 92663 Augr-rsta, CA 30901 1990 Jackson, C. Car:y, 300 20th Ave. N., Ste. 502, Nash- 1995 Morrsell, Edwin M., 4201 5t. Antoine SE-UHC, De- ville, Tlrl 37203 troit, Ml ,18201 1992 ,f ahn, Anthor:ry, 556 Eagle ltock Ave", Roseland, NJ 1988 Nadi:l, ]oseph 8., 243 Charles $i., Soston, MA 02114 07068 1987 Neclzelski, lulian M", Sunlybrook Medical 1982 iahrsdoerfer, Robert A., Universitv of Virginia Med. Ctr.,2075 Bayvier,r,' Ave., Toronto, Ontario, Ct:.. llox 430, Clrarloitesr.,ille, VA 22908 M4N3M5, CAIdADA 1987 Jenkins, !{erman A..6550 Fannin St., Ste. 1727, 1985 Neelv, l. Cail,517 S. Iuclid Ar,e., Box 8i15,5t" Houston, TX 77030 l-r:r"ris, L4f) 63110 1990 Jung, Timothy K.,3975 ]ackson 5t., Ste.202, River- .1995 Nelson, Ralph A., 2100 W. Third St., Ste. 111. Los side, CA 92503 Angeles, CA s0057 1988 Kamerer, Donald 8., 200 Lothrop St., Ste. 500, Pitts- 1995 Nipar:ko, John K., 601 N. Caroline 3t. 6th !1" Balti- burgh, PA 16211 mor:e, MD 21243-6442 1991 Karlr-rslr, Jack N'1., 27555 Micldlebelt Rd., Far:mington 1993 Olsson, James E", '1410 Meclical Dr. #550, San Anto- Hills, MI4B334 nio, TX 78229 1991 Katsarkas, Athanasios, Royal Victi:ria Hospital #E "1985 Pappas, Dennis, 2937 7lh Ave. 5., Birrningham, AL 4.48,687 Pirre Ave., W" Montreal, Qc, CANADA 35233 H3A 1A1 1983 lappas, Jarnes 1., 1020i Kanis Rt1., Little llock, AR 199t Kinney, Sam E., 60 lebblebrook l,ane, Moreland 722A5 l{i11s, OH 44022 1982 Parisier, Simon C., 186 E. 76th St., New York, NY 1991 Konrarl, l:lurst R.. SIU-PO Box 19662, Springfield, 10021 lL 62794-9662 2000 Parners, Lorne 5.,339 Windermere Rr1., London, On- 1993 Kumar, Arvind, 1855 W. Taylor St., Chicago, IL tario, Canada N6A 5A5 50612 1992 Pensak, MyLes 1.", PO llox 670528, Cincimrati, C)H 1999 Lalr,r'ani, Anil K., 400 Parnassus Ave., A730, San 45267 Francisco, CA 94143 1988 Pillsbury, Harold C., 610 Burnett-Womack Bldg 1995 Lambert, Paul R., MUSC-IO llox 250582, 150 Ash- C87070, Chapel t{i11, NC 27599 1e1, .1u"^, Charleston, SC 29425 1995 Poe, Dennis S., Zerc Hmerson Place, Ste. 2-C, Bos- "t997 Lec, K.1", 9B York St., Nen, flar.en, CT 0651 I ton, N{A 02114 1995 Leonetti, John I'].,2160 S. First Ave., Bldg t05-Rur 1969 Putec,Jack. 1245Wi1shireBIvd.Ste.503,Los Ange- 1870, Maywood, lL 60153 les, CA 90017 1993 Lesinski, S. Ceorge, 10550 Montgomery Rd. #34, 1999 Rizer, Franklin M., 3893 E. Market 5t., Warren, OH Cincinnati, OH 45242 44484 1999 l.evine, Samuel C., Box 396, 42tl l)elaware St., Min- 1992 Roland, Peter S., 5323 Harry Hir:res B1r.d, ]allas, l'X neapolis, N{N 554155 75215-9035 1987 i-indeman, Roger C.,6115 79th Ave., S.E., Mercer 1997 l{ubin, Atlal, 3065 Arlington Ave", Toledo, OH Island, WA 98040 43614-2807 1991 Luetje, Charles M",3100 Broadwal,, Ste. 509, Kansas 1989 Rybak, Leonarcl P., SIU PO I3ox 19638, Springfield, City, MO 54111 lL 62794 1987 Mangham, Charles A.,600 Broadr,r,ay, Seattle, WA "1992 Sasaki,ClarenceT.,YaleUnir.ersity,POBox20S04l, 98122-5371 Neu, Haven, CT 06520-804i 1985 Mathog, llobert H.,.{201 St. Antoine 5E, Detroit, M1 1990 Satalol{, Robert T., 1721 Pine St., Philadelphia, })A 48201 19103 1992 Mattox, Douglas 8., 1365 Clifton Rd., l\J[, Rm 2325, 1983 Schindler, Robert A., 400 Parnassus Ave., Rm Atlanta, GA 30322 A-730, San Francisco, CA 94117 .1979 Matz, Cregory, 2160 5. First Ave., Bidg 105-Rm 1995 Schleuning, Aiexander J.,3181 5.W. Sam Jackson 1870, Maywood, lL 60153 Park Rd., Portland, OR 97201 1987 McDonald, Thomas J., Mayo Clinic, 200 First St., 1990 $churing, Arnold C., 3893 E. Market 5t", Warren, S.W., Rochester, MN 55905 OH ,,14484 'lohn 1997 h4cElr.een ]r., '1'., 3404 Wake Forest Rd., Ste. 1993 $chr,vaber, Mitchell, 2400 Patterson St., Ste. 418, 303, Raleigh, ldc 27609 Nashville,TN 37203 j999 1999 McKenna, Michael J., 243 Charles 5t., llostnrr, MA Selesnick, Samuel H.,520 E.70th St., Ste.541, New 02114-3096 Yark, NY 10021 2000 Merchant, Saumil N.,243 Charles St., lloston, MA 1995 Shelton, Clouglr, 50 ld. Medical Dr., 3C120, Salt 02114 Lake Citv. UT 84132 76 TRANSACTIONS 2OOO I AMERICAN OTOLOCICAL SOCIITY 1973 Silversiein,l'ferbert, 1961 FloydSt.,Ste.A,Sarasota, 1989 ii968) Compere, Weslev 8.,4519 Mayapan Dr., FL 33579 LeMesa, CA 91941 1972 Si:rgleton, Ceorge T., Univ of FL - JHMHC, 3ox 1995 {L972) Crabtree, }ames A., 1332 W. Haven 11d., San 100264. Cainesviile, FL 32610 Marino, CA 91108 1993 Sismanis, Aristides, 1917 Windingridge Dr., Ricl,- 1989 (1958) Derlacki, Eugene L.,700 W. Fabyan ?kwy., mond, VA 23233 Batavia, IL 60510 1998 Smith, Peter G., 621 S. New Bal1as Rd., Ste. 597-C, 1994 (1974) Donaldson, James A., 600 Broadway, $ealtle, St" Louis, MO 53141 WA 98122 1979 Spector, Gershorr Jerry,517 S. Euclid, Box 8115, St. 1996 (19S7) I)oyle, Patrick i., 301-5704 Balsam St., Van- Louis, MO 63110 cou\ier, BC, V6M4 1997 Telian, Steven A., 1500 E. Medical Center Dr. 197L t1939) Druss,]osephG., 145E.92ndSt.,NewYork, TC1904L, Anr-r Arbor, Ml 48109 NY 10028 1996 Todct ]r", Norman Wendell, 1052 Castle alls Dr., 1993 (1971) Duvall, Arndt ].,420 Delaware St. S.8., llox Atlanta, CA 30329 396, Minneapolis, Ml'J 55455 2000 Tucci, Debara L.. Duke University Med. Ctr., Ilox 1999 (19S1)Eviatar,Abraham,2SMorrisLane,Scarsdale, 3805, Dcrham, hlc 27710 NY 10583 1997 \!ackym, Phillip A.,9200 W. Wiscr:nsin Ave., Mil- 1998 {1969) Gacek, Ric}rard, Dauphin St., Mobile, AL waukee, WI 53226 35606 1993 Wazen, Jack J., n\ f,.77th St., Neu, York, NY 10021 1997 {.1973) Ciasscock ll1, Michael 8., 420 Edmington 1990 Weider, Dudley ]., 38 Rip Rd., Hanover, NH 03755 Ave., Ste 14'15, Nashville, TN 37205 1998 Welling, D. Bradley, 456 W. l0tlr .Ave., Columbus, 1993 (1970) Harris, Iru,in,2160 Century Woods Way, Los Oi{ 43210 Angeles, CA 9{-}067 1987 Wiet, Richard i., 1000 Central $t., Stc 610, Evanston, 19% (1973) Harrison, l{i1ey H., Northwestern Medical IL 60201 Faculty Fnd., 707 N. Fairbanks Ct., Ste. 1010, Chi- 1992 Wilson, David F.,911 N.W. 18th Ave., Portlancl, OR cago, IL 60611 e72As 1990 {1972) Hilding, David A., 3156 S. Plateau Dr., Salt 1996 Yanagisawa, Eiji,9E York St., Nen, Haven, CT 06511 Lake City, UT 84109 1975 (1951) Hilger:, ]erome, 1700 Lexington Ave', Ste. 9t:nior Mrmbers 409, St. Paul, MN 55118 1999 (ISSB) Arlour, Kedar, 1000 Green St. #1203, San 1990 (1970) Hohmann,Albert,3lS4ShorelineLane,New Francisco, CA 94133 Brighton, MI.{ 551j2 1997 t197q Alford,BobbyIi..,OneBavlorPlaza,NA-102, 1990 (1960) Hr:ugh, Jack \u.D.,3400 NW 56th St., Okla- Houstor"r, TX 77030 homa City, OK 73112 1988 (1S60) Armstrong, Beverly, 3034 Hampton Ave., 1975 t5947) House, Howard P., 2100 W. Third St., l-os Charlotte, NC 28207 Angeles, CA 90057 1994 (1969) Baile;r jr., H.A. Ted, 1400 West N{arkharn, 1995 (1964) House, William F., Newport Lido Med. Ctr., Little Rock, AR 72201 361 Hospital ltd., Ste" 327, Newport Beach, CA 1990 (1958) Bellucci, Richard 1.,'162F. 7.Lst St., New York, 92663 NY 10021 i972 {1952) Juers, .Arthur L", 120 S. Hubbards Kabem 1S99 (1982) Boles, Roger, Box 620203, Woodside, CA #408, Louisville, KY 402Q7-3936 94062 1998 {1976) Kohut, Robert I., Bowman Gray School of 19SS (1c)61) Bradley, Wesley l{., 13 Saybrook E., Glen- Med., Dept. of Otolar,vngr:hgy, Medical Center mont, NY 1"2077-9rto6 Blvd., Winston*Salem, hlc 27157 19SS {1964) Rrockman. Seymour' 1., 222 3. McCarty Dr., I99I t\967) Linthicum Jr., Fred H., 2100 \{. Third St., Los Beverly !{ills, CA 90212 Angeles, CA 90057 1994 (1969) Buckingham, &ichar:d A., -I45 S" N.1,V. High- 1999 (1q88) Lippy, William l{., 3893 E. Market $t., War- way, Park Ridge, lL 6005E ren, OH,14484 2000 (1979) Cantrell, Robert W., Universit;z of Virginia 1995 (1969) l.itton, Ward 8., t7 Eagle Pointe Pass, PO Box lr{SC, Ilox 179, Charlottesville, VA 2290E 265, Ilapids City, IL 51278 1992 (1972) Caparosa, Italph J., 420 E. N. Ave. #402, Pitts- 1996 (1970) Maddox, H. Edward, 6249 Teri,r,i1liger, Hous- burgh, PA 15212 ton, TX 77057 1q96 (1975) Catlin, Francis L, 13307 Queensbury Lane, 1987 (1975) Marcus, Richard E., 5?1 Shericiar"r Rd., Wirr- Houston, TX77A79 netka, IL 60093 1994 {1973) C}randler, }. Ryan, 3170 Munroe Dr., Miami, 1997 (1965) McCabe, Brian F.,200 Hawkins Dr.-8230GH, fL 33133 Iowa Clty, 1A 52242 1992 (1969) Cocly, D. Thane, P.O. Box 523136, Marathon 1997 (1975) Montgomer:y, William W., 243 Charles St., Shores, FL 33052 Boston, MA 02114 19911 (1966) Co1e, James M., 1301 li.ed Lane, Danville, PA 1987 (1952) Moore, Tames A., 525 E. 68th Street, ]tlew 17821 York.l\Y 10021 TRANSACTIONS 2OOO I AMTRICAN OTOLOCICAL SOCIITY 191)4 {1971) Myers, Eugenc }'1., 200 Lothrop St., Ste. 500, 1994 (1987) Coir'r, Donald W., 7sq E" I-{arnpion Ave. Ste. Pittsburgir, PA 15213 51 0, Errglewood, C() 801 1t) 1994 (1963) Nager, Ce<:rge T.,550 1\. llroaelway, tlalti- 1997 (1987) Kelm, llobert ]., 13504 Creer Cedar L.ane, nrore, Ml) 21205-2020 Oklahoma Cit,v, OK 73131 1993 {1968)Naunton,Ralph}r.,DCSD-I{i|}CD-EPS-4008, 199S (19Sq) Marriglia, Anthony J., I1100 Euclid Ave., 6120 llxecr,rtive {Jlvd., l{ockvi11e, MD 20892 Cler,oland, Oi{ 4.11 06 2000 (19{iE) 1'apar:eltra, k{ichael M.,701 25th.Ar.e.3., Stc. 1997 (1936) farkin. ]an-res L., 10 Beecl-rltood Dr., Cob- 200, Minneapolis, Ml\l 55.1i5itr ham, Sr"rrrey, Llngiand KTl 1-2DX UK 1993 (1973) Penlingttxr, Ciaude {.., P0 Il*x 19i6, Macon, 1997 {19E9) []\:octor, Leonard l{., 8102 Hulton Rd., Balti- CA 31202 nrorsr, MD 21204 1998 (1989) Iladpour, $hokri, .i,1E1 IlV. 10lh St., India- rrapolis, IN ,t6202 lsslrclzltr Nlcwht'rs 1983 (195E) I(ambo,.].F1. T'hor-nas, 1Sil h" 77th St. Apt. BA, 1!92 Altschulor. Riclard A., 1301 N. Ann St., Anr: Arbor, New Yor:k" l{Y 10021 MI ,18109 19S3 (1972) I{itter, Frank N..2575 Inglave Dr., An;.r,Ar- .1995 Berliner,Kareirl., 119\zovageMall,Marinadel Rcy, bor, Ml .18197 {_A 90292 1991 (1969)Itobinson. l\4cnde11, l30WalermanSi.,Provi- 1979 Bohne, IJarbara A., Washington Uriv SOM Box rlence, ltl 02906 g1 15, St. l-ouis, M0 63110 1997 (lt)72)I{r:r-ris,MaxL.,.t601 WalnutSt.,#14u5,Phi1a- t97E Builer, IlobertA.,950E.ssrhSt.,Ci"ricago, IL60637 delphia, IrA 19102 1977 Cr-rsscn, Id*th, 312.4 l{eh;,rL:ilit;rtie,r Center, Los An- 1996 {1974) }lrrbeln, Robert,32100 Bainbriilge Ave., Creere ge les, C,A 9002'l Par:, Bronx, NY 1i)467 1992 H;rnid, N4ohamed A., 551 East Washilgton, Cl-ra- 1992 {1967) Rubin, Wtrllace, 343,1 F{ouma l}ir:d, 51". 23.t, grir Fal1s, OH 44022 Mct;:irie, LA 70006 1992 Hannley, Manre*n T., AAO-II|NS, One prince St", 1993 (1967) Ilrrggles, Iiicharrd L., 1i201 Shakcr 81r,r1., Alexandria, VA 22314 Clcveland, Ol{ 44104 1972 }1ar,r,kins }r., }oseph E., 130,1 l:i,rst Arrn St., Ann.Ar- 1994 {-1960) Sataloff, Joseph, l72l Pine Sl., Philadi'lplria, bor, \41 zl8igq IrA 19103 1989 Hinojosa, Iiar.rl, 53i6 Hyde i)ark lltrr,d, Chic*go. lL 1996 $972) Saunders, Williarn H.,456 W. 10ih Ar..e., Co- 60515 lumbus, OIt 43210 ]972 Honrubia, Vincr:nte, j0E33 LeConte Ave., Los An- I 9sE (1967) Shea, John l., 61 33 Popla r lrike, Memphis, TN ge les, CA 90024 381 l9 1973 lgarashi, Makoto, Nihon Unirrersitv 8-24 Kudarr- 19S4 (1965) Sheehv, ]ames L.,2100 W. Third St., Los An- min;rmi, zlchome Chiyo.1a-ku Tokyo 102, JApAhJ geles, CA 90057 102-0074 l9S0 (1958) Snith,.f. Brrriion, 2i lrarrirTgion Dr., Wi1- 1994 l:rato, Salvaiore 1., vin 1-,. Ricciriorri 10-N l-70124 lowdale. Ontario M2L 28,1 CANADA Bari, IIALY 2il00 (1973) Sarith, Mansfield F.W", 2400 Sanraritan Dr., 1997 fastrebo{f, Parn'cl J., 10127 Irost Way, E11icott, MD Ste " 1[i0, San Jose, CA 951?4 210,12 1993 (1q73) Snou,,'James I1., 33506 Tr-rckahoe ltiver I{d., Ig60 Johr-rson, Walter H., 30 Boncl St., Toronto, Ontario Easion, \4D 2l6ill MsB tWE, CANADA 1990 (1967) Stroud, M;rlco1m 1"1.,,1,11 2 Stanhope Ave", 1979 [ohnsson, Lars-Goran, Saynavakuja 486 $ipoo Dallas, TX 75205 12170 FII'{LAND 1990 (196i) Tabb, Harold C., 1430 Tulane Ave., Nen, Or- 1980 Juhn, S"K.. 2001 6th St. SE, Nllinneapolis, MN 55455 leans, LA 701 12 1969 Kiang, hielson y.S., 1B Cedar Lane l{ay, Boston, 1985 (1965) Iaylor", C. Dekle, 13500 Mancl;rrin lld., lack- MA 02109 sonville, [L 32223 1994 Kileny, ptrui R., 1500 11. yedica] ftr. Dr. TC 1904, i994 {1972) Ward, Paui H., 10833 LeCo:"rte Ave., Los Ar- Ann Arbor, h{l 4E109 geles, CA 90024 i97B Kimura, Robert S.,21 Wooddresterr Dr. Weston, MA 1996 (1975) Wehrs, I{oger {i., 6S09 S. [r,anston, [u]sa, OK 02493 741i6 1959 Lan rence, Merle, 27,43 Occan I)r., E-41 , Vero ileaci-r, 1989 {.1972) Wilson, Williarrr H., 1133 Oneicla $i., L)enver, FL 32963 Co 80220 1973 Lim, Davirl 1., 2100 West'Ihirrl St., 5rh F1, Los An- 1994 (1971) Wolfson, Roirert J., 2 Logan $quare , Ste. 181 1}, geles, CA 90057 18th 5t", betrn een Arch & Cherry 1997 l,onsburv-Martin, Brenda, Unirr. of Miami Ear Inst. Philailerlphia, IIA 19103 M805 PC llox 015950, Miami, FL 33136 l986 Merze nich, Miciraei, Univ. of CA Colcman Lab l{511 Ernt'ritus MLtrtbt:rs 871, San Francisco, CA 9,1143 2000 (i978) Ilrilton, B. 1{i11, P() llox 26901, Oklalron"ra 197! Miller, }r:sel M., 13{ll East Arn St., Ann Arbor, MI City, OK 73190 ,+8109 78 TRANSACTIONS 2OOO / AMERICAN OTOLOCICAL SOCITTY 1985 Morizono, 'fetsuo, Fukuoka University Medical 2000 Diamante, Vicente C., Pasteur 740, 1028 Buenos School, 814-01 ltrn Jonak-Kr-rflrkuoka l\anakuma Ailes, AIiCENT1NA 7-43-1,IAPAN 1997 Fagan, Paul A., 352 Victoria Street, l)arlinghurst 1978 Neff, William D., 3080 Hideu,ay Court, Morris, 11, 2O1O N.S.W., AUSTII.ALIA '1999 60450 Fraysse. Bernard Ci1, Dept ORL - Fiospltal Purpan 1996 Orchik, L)ar-riel ]., 6133 Poplar l)ike, Memphis, TN CI-{U de Toulouse, 31059 Toulouse Cedex, 38119 I]]TAN]CI] .i970 llosenblith, Walt*r A., M.I.T. Rm 3-240, Cambridge, 1998 Kim, Chong-Sun, Seoul National University Hospi- MA 02139 tal, 28 Yongon-Dong Chorrgno Cn, Seoul 110-744, 1986 itubel, Idwin W", Dept. of Oto-li.L-30 Univ. oi WA, KOItEA Seirttle, WA 98195 2000 Kr-ibo, Takeshi, Osaka University (EB). 2-2 Yamacl- 1989 l{yu, iai l{., Bonman Gray SOM, Winston-Sa1em, aoka, Suita, (Jsaka, IAPAN 565-0871 NC 27157 1996 Mann, Wolf J., Mainz Medical School 55131, Lan- 1975 Sarrdo, lsamu, 203 Lothrop 5t., Ilttsburgh, PA gelbeckstr. I D65101 Mainz, CERMANY Iall l 1996 Moffat, Dar-id A., 10 Addenbrooke's Hospital Hills 1992 Schact, Jochen, 1301 East Ann St", Ann Arbor, Ml Iioad, Cambridge CB2 2QQ, ENCLANI) 481 09 1999 Ocikvist, Lars, Dept. El.lT, University Hospiial 1950 Silverman, 5. Richard, 2431 NW 41sl St., Cairres- 5-581 85, Linkoping, SWEDEN vilIe, FL 32606 1997 Pyykka, Ilmari, lNT Department Karolinska Hos- 1962 Smith, Catherine A., 16200 S. Pacific fi1ty. #34, Lake pital S-171 76, Stockhr:hn, SWEDEN Oswcg*, OI{ 97034 1996 Rask-Anderson, Helge, Stigberssvagen 11,752 42, 1992 Snyder, Jack Mclean, 1661 Pine St., #932, San Fran- Uppsala, SWEDENT cisco, CA 94109 1996 Thomsen, Jens, HNT Department Gentofte Urriver- 1971 Thalmann, Rucdiger, tr{ashington Univ SOM 517 S. sity Hospital, DK-2900 Hellerup, DENMAI{K Euclid Avc., St. Louis, M() 63110 2000 WLlstrow, Thomas f.U., l{ND-Cemrin- 1970 Valvassori, Caldiro, 697 Sheridan Rd", Winnetka, schaftspraxis, Wiitelsbacherplatz 111I, D-80333 IL 60093 Munchen, CERMANY 1987 Van De Waier, Thomas, l(ennedy Ctr 302, 1410 Pel- Honurnry Membu's ham lkwy S., Bronx, NY 10461 1993 Albernaz, Pedro, 4405 NW 73rd Avenue Ste. 20- i974 Verrron,.fack A., 3515 S.W. Sam lar:kson Fark Rd., 40003, Miami,lll- 33156 Portlancl, 0R 97201 1993 llelal, Aziz, Ner-rrotology Section Alexandria Ear & 1999 Wright, Charles C.,5323 Harry Hines Blvd., Dallas, Eye Hospital, I Sidj Caber St. Alexandria, IiGYPT TX 75235 1993 Chlossone, Edgar L.,20423 State Road 7 Suite 6102, 1999 Wrrllstein, Sahina llegina, Oberer Neubergweg 10 Boca l(aton, lL 33498 D-97074, Wurzburg 1985 Fisch, Ugr:, Forchstrasse 26. Frcrbach, S}VlTZElt- .l984 Zr,,-islnck, Joseph J., lnst. o{ Sensorv Research Syra- LAND cuse Univ., Syracuse, NY 132,{4 1992 Colclstcin, jerome C., 4l1S Manchester Lake Drive, Lake Worth, F'L 33467 Cor respan d in.g M tttd:ers 1997 Flitselberger, William 8.,2227 Oceanview Suite .199, 1997 Antarasena, Soontorn, Dept. of Otolaryngologl, Los Angeles, CA 90057 Rahvithi l{ospitai, Rajvithi Road, Phyathai 1968 ]ongkees, L.B.W., Reijnier Vinkelelkade 71 1071 52 Bangkok I 0400, Tl{AlLAl.ilD Amsterdam, Wilhelmina Casthuis, THE lrlETHiilt- 1995 Bagger-Sjohack, Daniel J., Dept. oI Otolarvngology LANDS Kar:oiinska l{ospital, 17176 Stockholm Sl0ai, SWE- 1985 Morrison, Andrer,, "Dyers" Marden Ash Chipping DEN Ongar, Essex CMS 9BT, UK 1995 Booth, l. Barton, 1B Upper 1{impole Street, l,orrdon 1992 Nomura, Yasuya, Showa Univr:rsity I-5-8 Halano- W1M7TB, U.K. dai, Shinagawa-Ku Tokyo 142,IAPAN 1995 Car-rsse, lean-Bernard, Villa Anfa L'Ardide Haute, 1983 Portmann, Michel, 114 Ave de' Area, Bordeaux Route de l,lauleihan 34500 Beziers, FIiAI',JCE 33OOO, FRANCE 79 TRANSACTIONS 2OOO I AMTRICAN OTOTOCICAT SOCIITY AMTRICAN OTOLOC:CAL SOCIETY, INC. D TCTASE D (1 9e6*1 eeg) Actine Mewbers 1S73 (1953) Clorig, Aram, 9941 Westhar,en Circle, l{esl- 1989 (1965) Moon, Cary N" JL., 1135 Inglecress l)r:., Char- minster, CA ?2683-7552 (DieLl 1998) lottesville, VA 22901 {l}ied May 19,1997) 1978 (1957) Myers, Davitl,2700 N. Forest Rd., #123, Cetz- 1983 (195?) Proud, Gunner O.,3721 W. 87th St., Sllaw-nee vi]le, lrJY 14068-1527 (Died May 3, 1998) Mission, KS 66206 (Died March 15, 1997) 1975 (1950) Shambaugh, Ceorge Jr., 40 3. Clay St., Hins- 1987 (1966) Schlosser, Woodrow D., Fort Pierce, IL {Died dale, lL 60521 {Died 1999) October 9, 1996) 1971 (1947) Stuart, Edwin A., Carnp Hill Hosp., Haliiax, 1957 {1990) Schuknecht, H*rold F., Boston, MA (}iecl Nova Scotia, C.rnada (Died May 21, l9e8) October 19, 1996) 1987 (1964) 1A/right, Wiiliam K., 3671 Delmonte, Hor-ts- i9S4 (1974) Torok, Nichoias, Clarendon Hills, lL (Died ton, TX 770i9 {Dled 1998) Apri130, 1e96) 19s2 {1q75) Powers, W. Hugh, 728 Willow Way, $imi, 1972 {1946) Truex, Edr.vard H.,37 Farmington Rd., Weth- CA 93065 (Died 1999) ersfield, CT i16109 (Died Dec. 5, 19S6) 1991 (197,1) Michelson, Robin P., 886 Edgewood Rd., Emtritus Mtt'ttbtrs Redwoori City, CA 9a061 (Died ]une 27, 1997) 1974 (1963) Ilovd, l-{arold, Retlondo l3each, CA (Died 1981 (1962) Waltner, Jules, Nelr, York, (Date of death un- ll{arch 19, 1997) known, 1997) 1S73 (1957) Tolan, Jr:lm F", 3419 47ih Ave. NE, Seattle, 1990 (1958) Cody, Claude C. 111, 529 E. Friar Tuck Ln., WA 98105 (Died h,farrh 16, 199S) Houston, IX 77024 (Died November 14, 1997) 1995 (1973) Sinrmi:ns, F" Blair, 300 Pasteur Dr., Rrn. dssorinle Me*rbers R-135, Palo Alto, CA 94025 (Died February 13, 1998) 1954 Craybiel, Ashton, M.1).. Warrirrghn, FL 1971 Ward. W. Dixon, Ph.D", Falcon Heights, MN (Died Sexiar Mewhers December 19, 19S6) 1981 (1961) Daly, John F., 1500 Ialisade Ave., #27C, Fort 1973 Cesar Fernandez, M.D., Chicago, TL (Died Decenr- Lee, NJ 07024-5318 (Died October 21, 1998) ber 15, 1999) 80 INDEX suBfECr rNDrx Acoustic tumor, cochlear ir:rplant afle: Ft'iirrc irnmunr'dlficielrc) viru*. Mdniire's diseasc removal of, 34, 36*37 mediation o{ gene lherapy of intractable, veslibular nerve section Ar:lericar Otologiral Societv midclle *ar rnu.osa ceils bv, 6, anri labyrinthectomy for, 2s, 30*31 Award of Melit, ix, x I 0*1; quality of life and, 28, 30*3i executive sessions, 66-69 Fernandez, Cesar, 70*71 Microsurgery, acoustic neuroma and, guest(s) of honor, 3-4, x 50*57 members of Middlc r:ar deceased, ll0 Camma knife, acoustic neurofila and. muco$a cells of, feline nen,73_7! 50-57 imn-rr'nod eficiency rrirus-mltdiated Cene iherapy oI middle ear mucosa cells, nerq, presidell,65 gene iherapy of,6, 10*11 fclin,' irrunr'dt.ficiency r iru- officers, viii prr,lr'ngcJ r ettlil,ttion of. mediatior": of, 6, 10-11 Presicler-rtial Addr*ss, l-3 ty:lpanoplasty and, T-tube for, Centa*ycin, intratympanic therapy with, nl 1a Presidential Ciiation. 5 hearing results with, 27, 30-31 prosthesis for, displacement in high jug:-rlare Clixr-:s tumor, comparison o{ strength magnetic {idds of, 13, 15 Ki-n7 and C-F( )5 -idining p,rttprnc IlAl:1A (bone-anchored hearing aid), surgery of, irnplants in, 9, L0-11 in, 41, 42*rl3 38*39, tt2-43 ( ,lLrntu- t) mpJni. unt tilntor. s1,6p3;j11',1 Balancetrak 500 findings, of Ki-67 and C-FOS sta:ining Neunale, hearing loss in, risk factors for, elec:ronvstagfl ography rs. patt€rns in, 41, 4243 pr:stu:ography. 62, 65 ,t5, 48-4S Borre-anchored l-reraring aid. (BAHA), Neuroma, acr:uslic, 50-57 38-39, 42-43 Hearing loss conservative management oI patients conductirre, histopathology of residual tciih, 40, 42*43 ,urd rt.crrrrcnl. following Cholesteatoma stapedectomy, 59*60, 64 canal wall-up vs. canal wal.l-down neonatal, risk lactors for,,15, 48*49 Ossicuioplasty procecture and, i6-21 prognostic lactors in, 14. 15 surgery for, facial nerve dehiscence at, prostheses use for, 9, 10*11 25,26 lmaging. See al'o speci{ic tecirniques 0iosclerosis Cochlea, severely r:ralformed, cochlea clinical diagnosis of inner ear ccnservation o{ stapedia.l tendon in implantation wkh, 32, 36-37 disorders and, 47, 48*49 sursical correction of, 8, I0*11 Cochlear implanl lmplants {ar-advanced, co.hlear implants and, acou$lic luxor removal and, 34, 36-37 cochlr:ar (See Cr:chlear implants) 33, 36*37 c), aduit, new elecirode technology and, in middle ear su:gery. 10-11 posterior st;rpediovestibr.rlar joint in, 35,36*37 Inne: ear histr:logic slud:ies of, 51, 55 marlagement ol far:-advanced disorders oI, imaging in clinical otosclerosis with, 33, 36*37 diagnosis ot,47,48-49 lidocaine perfusion of, plus IV severely malforme,:l cochlea and, 32, Phenotype, vestibular, Waarrlenburg's JO-.)/ lidocaine, tinnitus and, 24, 26 Intratvmpanic therapy, gentamycin for, syndrome and, 63, 55 Cochleovestihular disorders, Fowers, W. Hugh, 72 hearirrg results with, 27,3011 inrr:rure-:tlediated, etanercept Prosil-resis, middle ear, displacemeni in tirerapy for, 44, 48-'49 high strength magnelic fields, 13, Compuler model(s), inte.acti\.e, R.H., ix 15 3-dimensional, o{ temporal bone, lahrsdoerfer, 5E Labvrintheclomy, vest.ibular nerrre Rildiosurgery, acouslic neuroma and, $ection and, intraclable Mdni0re's 50*57 Elecirode technology, new, adult disease and,29,30*31 cochloar implants tncl. 35, 36*37 Lidoca.ine, inne: ea:: perfusion with, plus filecironvslagmr:graphy, vs Balancetr ak lV lidocainc, iinnitus and,24,26 500 fin BT AUTHOR INDIX "f-tube, subarnllar, pr"olongeri Tinnitus, liclocaine perfr:sion ol the ir':lcr Vestibuiar ;rerve sr.riior-r, labyrirthectorn-v middle ea: vi:ntiiairolr during ,:ar phrs IV lidocaine 1or,14,26 and, inlraclabic Mdniirc's dise;:sc tympanoplastv ard, fy:rpaniclm lumors, Ki-67 r,s C-F(}S anc{, 29, 30-31 22*73 sia1l1ir1g patterlts in, 41, ,12'-43 I'cmporaI bone, inir:ractivt, T-vmpanoplasty, prolonged middle ear 3-dimensional comprtcr modcl of, veniil;rtirx tluring, subann uli:r Waardenburg's synd1 ofie, \.e$tihu1;u' 'tr-trrbe flr 5E lor,22-23 Ih,'rrutr 1',' "1 ',i AUTHOR INNTX Ahmadi, A:ris A., 29 lirr:c:r, Doi-rg, 26 O'Conlror, Calhleen A., 4l) Alexiades, (leorgc, 32 (iu11';-i, A..luliana, 66 Oais, 15 Alle:r, K., 63 Custa{son, Mark, 4E Obr':itsch, Weslev, 6 Arnin, Manali,62 Ogbrrger, Marv Joe, 35 Anderson, P., 2E l{a1at,a, Ashrai A., 7 lohn Iappas, Dtnr:is C., 41 Arrtonelli, latrick 13, 2S, 30 Hamlci, h''loha*ed, 48 .1., Parisier, Sinror, 1E-19, 20, 2l Arts, H. Alcxandcr, 38*39 ] {arrrer, Stepherr i,., 27 .Perkins, llocine\ C., B, 11 Harris, jeffrey f., 28, 31 lesznccker, S.C., 63 Backous, Doug, 15 ]{ilman, )e;n li., 41 Peterman, I)errick W., 12 }{oistad, Dick 1.,., 4il, 42 Bae,1{al Soo,,17 1'hillips, l)ianr:, 45 I{ughcs, I-alry- F-, 62 lJancc, 49 Pickott, Llrad, ,13 Beatty, Charles W., 27 Poe, Demis 5.,7, 44 l:rcesr:|:, Armagan. {rl Beial, Aziz, 34 Potsic, William, 38-39 Beiiucci, Richa::d, 10 houye, Masa,vuki, 38 Pulec, Jack, 10-11 Bigelorv, Douglas C., 33 Black, 1".O., 63, 65 Jackson, C. Cary, 1-3, 3,5, 15, S6 Rafler, Krisiine 0., 3l Brackmann, Deraid H., l-{, 38-39, 50-5i, l{ahrnan, Mahbur! 1.1., 44 s5, 56 .K;rlrcr*:, lfon, 42 l{azek, Osar:a A., 7 Kilenv, ?aul R., 35 Iioberst.rn, ]oseph, 58 Konrad, l-lorst R., 62,67-b9 llodne;:, 8 Churg, C.Y.]oseph, 45 -fhomrs, Kountakis, Stilianos !.., 45 32, .|1, 42, ,13 Choi, H1,o11 K., 44, 18, 49 Roia:rd, .1. Arvinr-1, ,17 ., Chole, Rick, 15 Kum;ll, IlLrber-rstein, larr I 38-39 Colrer-r, Noel 1,., 32, 3{i llubin, Al1an, 65 Coker, Nervion, 30 l,ar:-lbert, fau1, 1.6-17, 20, 2l Ruckolsicin, lvlichael J., 33, 3$.37 l,esinski, Cerorge, 1.1) Ruggles, Dick, 26, 3i) l-iri, lizhcr, 6 De I,a Crr:2. Tony, 37 Scitlm;l, Michacl, 30, 42 l-isuk, John, ,19 Dharrda, Ilcena, 22-23 Samur:l H., 25, 26 l.,uttje, Charles, 15, 30, ix Srbsr-rick, DiVene:e, Scoii W., 47 Sl'rea. l{1,24,31, {{:,;18-49 l-usiig, l-ar,r.'rence R., 3E-39, 42 Jolrn J., Jt., lljalilian, Haxid R.,6 Silvcrsteir, Herber t, 65 Lvrn-1\4.rclae, Alaslair: C., 2E L)ornhoffcr, Johr L., irl Singlcion, Ceo:ge T., 2! Driscoll, Colin L.W., 27 Skor-rliis, John, 45 .lE Mahfee, Mahinood, 47 Duckert, I-arry, 43, S*:ilh, Mansf:iek1, 3{r .lvI:rrrrikoglu, lluient, ilO Smilir, Shalrn, 35 MtDonalcl, Thomas 1., 27 Elluru, Ravindhra C., 22*23 Sri r:err1rlr, Sha:mi lla, 38*3!) Mcllr,een, Johl, 36 Strpharidrs, \4ichae1, 58 Emmeil, lohn i{., !) McKcnnan, Kerrin, 21, 3]., 53*55, 55*57 Svms, fharles A. l1l, 3E-3, Meger:ian, Clili A., 38-39 Svms, \,lark 12, i5 Facer, Ccorge W., 27 Melnik, Ceolgo A., 40 J., Facer. Miclir:lle L., 27, 30, 31. Merchant, Saun-ril li.. 6l 'lakahashi, Cril, 38-39 lislrman, Andren, J., 32, 3{: Mills, D;:*,ra, 35 T'elian, Sleve, ,13 Flickinger. 50, 5.1 55, 56 -52, Moior-rv, Tim, 38-39 Thompsen, Jcns, 52153, 55, 55, 57 Francis, l{or,vard F., 38-3q Monsell, Ed, 65 Tsuboi, Yasul-riro, l: Friedman, t{ick, 3{.) Monlgomery, Kcvir"r, 58 Mooro, (iarv F., 3E 39 Yr:rnick, David, 38-39 Gantz, Brrcc, .16, i7, 18, i9*:0,21,42 \4oore, Karen M., 3B-39 Wackrmr, Phillip A., 38*39 Cardrer, Idt,ard K., i4 Morrorv, Trish, 3E-39 Weide:', Dudlev, ,11 ,+6 Mr.rjiaha, 41 Ce, Xianxi, 21,76, Mohanrmed, l,Veli1ng, Brad, 36, 50, 53"56, 57 Clianna, Clairer, 63 Wiert, Richarci I., 36. 40, !t2--13 Cianoli, Cerr-v, 2{: Nado1, B., l7-18, 20*21, 59-50 Joseph lr., 1{i1.lians, l,*rna, 1 3 (lirar:rli, 65 .13, Maria;r, 62 61, lViiliams, Michelle D., 15 42 C1vla, l{obelt J., 61 Ncdzelskj, Julian. \{1l1iams, William 3., 5 Coebel, Joel A., 22-23 1\'eeii,, .l.Cail, 22-23 Goldenberg, Itobert 4., Ll Niparko, lohn K., 3E*39 Zrtolan, Tcrry,35 82